CPAP Compliance Report (LCD) Patient
Homecare Provider Name:
TOM SMITH
Name:
(Please Insert Name)
Address:
1135 Washington Blvd Springfield CA92064
Address:
(Insert Address)
Phone: Fax: EMail: ID: Age: Sex: Height: Weight: BMI:
555-6398 555-6399
[email protected] 1212 45 male 6' 220lb 30 Insurance Carrier: Phone: Fax: Policy Number: Sleep Lab:
Phone: Fax: EMail:
(Insert Phone Number(s)) (Insert Fax Number)
Physician
Kaiser 555-3130 555-2118 OSA3456 Sleepwell
Name:
Dr Johnson
Address:
268 Washington Blvd Springfield CA92064
Contact: EMail:
Pamela
[email protected]
HC221 Serial Number: Prescribed Pressure Setting:
SAMPLE_FILE 10.0
Initial Setup Date: Mask Type on CPAP: Report Date:
Jan-01-2004 Aclaim Jul-23-2004
Humidity Setting ..................................................................
2
Avg. Patient Compliance ....................................................
6.5
Total CPAP Usage (hrs) ......................................................
1624
Total CPAP Usage (days) ...................................................
204
Avg. CPAP Usage (per night) .............................................
8.0
* Data Verified By Checksum.
Printed:
Jul-23-2004 Fri
Page
1
CPAP Compliance Report (LCD) Comments
This SAMPLE FILE is to demonstrate report writing capabilities.
Printed:
Jul-23-2004 Fri
Page
2
