1. This completed compliance cover sheet
2. The short summary compliance form obtained from the PAP device manufacturer’s software
Member Name:
DOB:
Member ID#:
Physician Name:
NPI:
Address:
City / Zip:
Phone:
Fax:
DME Provider:
TIN:
Address: City / Zip:
Phone:
Fax:
RSPLY Request: Select one type of mask and one tubing
Page 1 of 1
PAP Resupply Cover Sheet
Please fax the following documents to the corresponding number at the bottom of the page to request
authorization for PAP Supplies:
Mask
Tubing
A7037 Standard PAP Tubing
A4604 Heated PAP Tubing
A7027 Combination Oral / Nasal Mask
A7030 PAP Full Face Mask
A7034 Nasal Mask
A7044 PAP Oral Interface
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
Please fax information to the corresponding fax number below:
For general sleep inquiries, please call 888-511-0401
866-999-3510
February 2020
5
On average, how many nights per week does the patient use the PAP device? __________
What is the average number of hours per night that the patient uses the PAP device? __________
Has the patient been contacted directly to determine compliance and required supplies? Yes No
Have the patient's sleep apnea related symptoms continued to be under control? Yes No
