ResMed Prescription Form
This document serves as a prescription template for ResMed devices and accessories.
Patient Information
Patient Name: [Patient Name]
Address: [Patient Address]
Email: [Patient Email]
Diagnosis: OSA ? Hypersomnia with sleep apnea ? Other: [Other Diagnosis]
Physician Information
Physician Address: [Physician Address]
Physician Phone Number: [Physician Phone Number]
Physician Fax Number: [Physician Fax Number]
Order Details
Order Date: [Order Date]
D.O.B.: [Date of Birth]
Phone Number: [Patient Phone Number]
Diagnosis Test Date: [Diagnosis Test Date]
Duration of Need: 99 months ? Lifetime ? Other: [Other Duration]
*Lifetime is default if left unchecked.
APAP™ Therapy
Therapy Device:
- AirSense™ 11 AutoSet™ (with integrated HumidAir™ humidifier) ?
- AirSense 10 AutoSet (with integrated HumidAir humidifier) ?
- AirMini™ AutoSet ?
Therapy Modes (select only one):
- AutoSet mode ? DEFAULT
- Default mode settings
- Min. pressure: [Min Pressure] cmH2O (4-20cmH2O)
- Max. pressure: [Max Pressure] cmH2O (4-20 cmH2O)
- Ramp time: [Ramp Time] min(s) (Auto, OFF-45 min.)
- EPR™: 1 ? 2 ? 3 ?
- AutoSet for Her mode ?
- CPAP mode ?
- Default mode settings
- Custom settings
- Pressure: [Pressure] cmH2O (4-20 cmH2O)
- Ramp time: [Ramp Time] min(s) (Auto, OFF-45 min.)
- EPR: 1 ? 2 ? 3 ?
Settings:
- Min. pressure: [Min Pressure] cmH2O (4-20cmH2O) 20 AUTO
- Max. pressure: [Max Pressure] cmH2O (4-20 cmH2O) 20 AUTO
- Ramp time: [Ramp Time] min(s) (Auto, OFF-45 min.) 20 AUTO
- EPR™: 1 ? 2 ? 3 ? AUTO
- AutoSet for Her mode ?
- CPAP mode ?
- Default mode settings
- Custom settings
- Pressure: [Pressure] cmH2O (4-20 cmH2O) 10 AUTO
- Ramp time: [Ramp Time] min(s) (Auto, OFF-45 min.) 10 AUTO
- EPR: 1 ? 2 ? 3 ? AUTO
Mask Interface
Full face masks:
- AirFit™ F40 ?
- AirFit F30i ?
- AirFit F30 ?
- AirFit F20 ?
- AirFit F20 for Her ?
- AirTouch™ F20 ?
- AirTouch F20 for Her ?
- Fit to patient comfort ?
Nasal masks:
- AirFit N30 ?
- AirFit N30i ?
- AirFit N20 ?
- AirFit N20 for Her ?
- AirTouch N20 ?
- AirTouch N20 for Her ?
- AirTouch N30i ?
- Fit to patient comfort ?
Nasal pillows masks:
- AirFit P30i ?
- AirFit P10 ?
- AirFit P10 for Her ?
- Fit to patient comfort ?
Therapy Accessories
- ClimateLineAir™ heated tube ?
- SlimLine™ tube ?
- AirMini tube ?
- Combo mask oral cushion ?
- Combo mask nasal pillows ?
- Chinstrap ?
- HumidAir humidifier tub ?
- Nasal pillows cushions ?
- Full face cushions ?
- Filter, disposable ?
- Nasal cushions ?
- Headgear ?
Connected Health
- Wireless monitoring ?
- Add a physician to AirView™ ?
- Invite patient to sign up for myAir™ ?
Notes
Directions for use: Use at night while sleeping ?
Dispense as written ?
Statement of Medical Necessity
The above patient has undergone a diagnostic evaluation. This evaluation has confirmed a positive diagnosis of sleep apnea. Positive airway pressure therapy is medically necessary and provides effective treatment of this disorder.
Practitioner Signature
NPI #: [NPI Number]
Practitioner Name: [Practitioner Name]
Practitioner Signature (signature stamps and date stamps not permitted): [Practitioner Signature]
Signature Date: [Signature Date]
This prescription template is provided solely as a convenience to licensed healthcare providers. It is not intended to dictate clinical decisions or to serve as medical advice. The prescribing healthcare provider is solely responsible for determining the appropriate device, treatment, and any specific instructions for each patient based on their individual medical needs.
ResMed Shop is operated by Expedite LLC, a ResMed company.
Expedite does not accept any insurance.
Notice to Medicare and Medicaid Beneficiaries: Medicare and Medicaid will pay for durable medical equipment and supplies only if a supplier has a valid Medicare or Medicaid supplier number and meets all other Medicare and Medicaid enrollment and product coverage requirements. Expedite does not have a Medicare or Medicaid supplier number. Medicare or Medicaid will not pay for any medical equipment and supplies we sell. You will be personally and fully responsible for payment and agree not to appeal if Medicare is not billed.
Expedite LLC, 9001 Spectrum Center Boulevard, San Diego, CA 92123 USA (833) 968-2727
Air10, Air11, AirFit, AirMini, AirSense, AirTouch, AirView, AutoSet, ClimateLineAir, EPR, HumidAir, myAir, ResMed, and SlimLine, are trademarks and/or registered trademarks of the ResMed family of companies.
