SMIT Referral Intake App

Patient Information

Patient Name Date of Birth Gender Patient Email Phone — Home Phone — Cell Insurance Card Upload (photo or PDF)

Provider Information

Provider Name Provider Contact Person Provider Phone Provider Fax Provider Email

Territory / Sales Contact

Reason for Referral (ICD-10)

Obstructive Sleep Apnea (OSA) Snoring Excessive Daytime Sleepiness (EDS) Fatigue Insomnia Pulmonary Hypertension (PHTN)

Additional Reason

Services Requested

Consultation & Management Sleep Testing CPAP/BIPAP Device or Supplies AIO Breathe® Adults AIO Breathe® Children 6–17

Routing & Signature

Routing Destination Referring Provider Signature (typed) Signature Date

Sleep Medicine Institute of Texas — Referral Intake App