Enclosed on Page 5 is an authorization form to release your health information.

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1 Monitor Medical, Inc. "The CPAP Co." Ph: (877) Fax: (888) Dear Medicare Beneficiary: Thank you for selecting Monitor Medical, Inc. to provide you with all of your sleep apnea needs. Please be patient with your doctor, sleep lab, and Monitor Medical while obtaining the paperwork that Medicare requires. Your documentation will be reviewed to meet Medicare criteria; Delays may be the result of obtaining the correct information. Enclosed on Pages 2-4 is an overview of Medicare required documentation. You may bring this to your doctor to review when requesting for your medical records. Enclosed on Page 5 is an authorization form to release your health information. Enclosed on Page 6 is a generic prescription form that your doctor can complete to order your equipment (An Order and Signature date must be filed in). If you are unable to obtain the required Medicare documentation, you may still purchase the PAP equipment on your own, but Monitor Medical cannot file with Medicare on your behalf. Please visit our website at: where you can view products, sign up for newsletters, view promotions and much more. Copyrighted 2016 Page 1 of 4 Updated July 2016

2 If you received your initial PAP device before November 1, 2008 or received your PAP through private insurance and now seeking Medicare coverage of items, we will need: A current (within 12 months of present date) office note signed by your doctor discussing your history with sleep apnea, your current usage and benefit with PAP therapy, and the medical need to continue usage. A copy of your diagnostic sleep study showing your AHI (Apnea Hypopnea Index) or RDI (Respiratory Disturbance Index) is greater than or equal to 15 or your AHI/RDI is between 5 to 15 with mention of daytime sleepiness. *Respiratory Effort Related Arousals (RERAs) are not considered to be part of the calculation of AHI/RDI. The doctor who signs the sleep report may need to be sleep credentialed. A current prescription (within 12 months of present date and also within 6 months of office note if getting a PAP. Rx is also known as a Detailed Written Order, see Pg 3 for more info). Medicare requires the following items for new and existing PAP (CPAP or Bi-PAP) beneficiaries set up on or after November 1, 2008: Treating Physician s initial face-to-face notes of a clinical evaluation with the patient prior to a sleep study, to assess the patient for Obstructive Sleep Apnea (OSA). These notes must be signed by the physician. Notes must be current within 12 months if obtaining a PAP. A sleep study from a Medicare approved sleep entity dated on/after the initial face-to-face with the AHI 15 or AHI of 5 to 15 with mention of daytime sleepiness. The physician signing and interpreting the sleep study must be credentialed according to Medicare guidelines. A current prescription (within 12 months of present date and also within 6 months of office note if getting a PAP. Also known as a Detailed Written Order, see Pg 3 for more info). Additional requirements after first 3 months of PAP Therapy: Objective evidence of adherence to use of the PAP device (download report), reviewed by the treating physician. Adherence to therapy is defined as use of PAP 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. A Face-to-face clinical re-evaluation by the treating physician with documentation that the beneficiary is using and benefiting from PAP therapy, no sooner than the 31st day from setup. Copyrighted 2016 Page 2 of 4 Updated July 2016

3 Copyrighted 2016 Page 3 of 4 Updated July 2016

4 Copyrighted 2016 Page 4 of 4 Updated July 2016

5 AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION (PHI) Patient Name: Last First M.I. Address: Date of Birth: MM Chart Number/State: If this Authorization is for any purpose other than the release of PHI for personal reasons, please state the purpose below: I authorize the release of medical records from: Please release requested medical records to: Name: Address: City, State ZIP Telephone Number: Fax Number: I specifically authorize the use and disclosure of the following PHI: (Please provide a detailed description of the particular data and period of time you are requesting. All records should be sent if not indicated) Insurance Information Sleep Studies Hospital Records Progress Notes Clinic Records Other This authorization will expire on the 180th day of the signing unless a lesser date is specified below: By signing this Authorization Form, I understand that I am giving my authorization for Monitor Medical, Inc. to use and/or disclose my protected health information (PHI) as described above. The information to be used or disclosed pursuant to this authorization form may include information relating to: (1) Acquired immunodeficiency syndrome (AIDS) or (2) human immunodeficiency virus (HIV) infection, treatment for drug or alcohol abuse, or (3) mental or behavioral health or psychiatric care. If you are requesting psychotherapy session notes maintained by a mental health provider, a separate authorization form must be completed. I understand that I may revoke this authorization at any time by notifying Monitor Medical, Inc. in writing to the Health Information Management Department, South Kirkwood Rd #203 Stafford, TX of my intent to revoke this authorization. I understand that such a revocation will not have any effect on any information already used or disclosed by Monitor Medical, Inc. before Monitor Medical, Inc. received my written notice of revocation. If neither federal nor Texas privacy law apply to the recipient of the information, I understand that the information disclosed pursuant to this authorization may be re disclosed by the recipient and no longer protected by federal or Texas privacy laws. This Authorization is voluntary and I may refuse to sign this Authorization Form. I understand that I am not required to sign this Authorization Form in exchange for the patient receiving treatment from Monitor Medical, Inc. Signature of Patient or Authorized Personal Representative Date Relationship to the Patient (If signed by a Personal Representative) Date

6 Order date: Start date: PAP Rx/ LMN Fax medical records & Rx to: (Order and start date must be completed. It may be the same date.) The patient: DOB: Chart or HIC #: Responds well to therapeutic positive air pressure. Patient s Address: 1. Auto PAP OR C-PAP and Heated Humidifier at: cm H 2O. (Max: 20 cm H 2O). 2. BiLevel S and Heated Humidifier at: IPAP: cm H 2O, EPAP: cm H 2O (Max: 25 cm H 2O). 3. BiLevel Auto and Heated Humidifier at: IPAP Max: cm H 2O, EPAP Min: cm H 2O (Max: 25 cm H 2O). 4. BiLevel S/T and Heated Humidifier at: IPAP: cm H 2O, EPAP: cm H 2O, and Breathing Rate of: per min (Max: 30 cm H 2O). 5. ResMed VPAP Adapt SV and Heated Humidifier at: EEP: cm H 2O Pressure. Min. Pressure Support: cm H 2O (Range 3 6). Max Pressure Support: cm H 2O (Range 8 16). Backup Rate = AUTO (EEP + Max Pressure must not exceed 25 cm H 2O) 6. Respironics BiPAP autosv Advanced and Heated Humidifier at: EPAP Min: cm H 2O, EPAP Max: cm H 2O, PS Min: cm H 2O, PS Max: cm H 2O, Max Pressure: cm H 2O, Rate: AUTO. Bi-Flex: OFF. (For treatment of conditions such as periodic breathing, cheyne strokes, Central Sleep Disorders, or Complex Sleep Apnea) 7. Respironics AVAPS and Heated Humidifier at: IPAP Max cm H 2O, IPAP Min: cm H 2O, EPAP: cm H 2O, SET V t:, Rise, Rate. C-PAK (Complete Positive Air Kit) 1 Nasal/pillows mask & headgear every 3 months 1 Full-face mask & headgear every 3 months 1 Hybrid mask & headgear every 3 months 1 Oral mask & headgear every 3 months 1 Disposable water chamber every 6 months 1 Chin strap every 6 months 1 tubing every 3 months 2 Nasal cushions/pillows every 1 month 1 Full-face cushion every 1 month 2 Hybrid cushions/pillows every 1 month 1 Headgear every 6 months 1 Non disposable filter every 6 months 2 Disposable filters every 1 month 1 Heated wire tubing every 3 months Diagnosis: Obstructive Sleep Apnea G47.33 Central Sleep Apnea G47.31 ALS G12.21 COPD J44.9 Other X Physician Signature Print Name Date N.P.I. #: The signature and signature date cannot be stamped. STATEMENT OF MEDICAL NECESSITY: PAP is necessary for Lifetime The beneficiary has had an in person examination with a treating physician within six (6) months prior to the date of this prescription. The beneficiary has been evaluated for a condition that supports the need for the items being prescribed. The above patient has undergone a clinical or polysomnographic evaluation. This evaluation confirmed the diagnosis of apnea or respiratory failure. As the patient showed both significant oxygen desaturations and abnormalities secondary to apnea, nasal CPAP/BiPAP is medically necessary. HEATED HUMIDIFIER: The patient suffers from a dry airway and difficulty in breathing. The appropriate remedy to this problem is the addition of an in-line heated Humidifier, used in conjunction with the positive airway pressure. The added moisture will allow my patient to use the treatment device successfully. C-PAP SUPPLIES: It is necessary to replenish supplies so that incidents of respiratory infections are reduced and patient compliance can be improved. (Revised: 11/5/2015) X