Resources, Forms and Patient Flow by Jan Palmer


Enjoy a more efficient dental office with professional forms from Jan Palmer Co in association with and others. Choose a package with the best value for your office or bundle all 3 and save!

Digital files are available from your account for 30 days and are sent by email in the form of secure links.


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Forms will be emailed in Word or PDF Format so you may add your letterhead and logo.
These forms are protected by copyright. You are not permitted to share them with other providers.

Package 1: Helpful Resources​​​​

Includes valuable resources to the dental sleep administrator compiled in 1 place:
✓ Resource page with many helpful website links including links for Advanced beneficiary Notification instructions, requirements and blank form
✓ Acronyms and terminology, General
✓ Acronyms and Terminology, Medicare

Includes Complimentary Forms:
✓ Sleep Hygiene
✓ Epworth Sleepiness Scale
✓ Medicare supplier standards
✓ Local Coverage Determination
✓ Article A55426; Standard Documentation Requirements
✓ STOP BANG evaluation
✓ Websites for daily use

Package 2: Essential Forms​​​

Includes 12 valuable forms for the dental sleep practice, included are:
✓ Assignment of Benefits and Acknowledgement to Submit Claim to Insurance
✓ Insurance Verification Form
✓ Medical Records Release
✓ New Patient Intake Form
✓ Non-participating Financial Contract, Medicare
✓ PAP Intolerance Affidavit
✓ Participating Financial Contract, Medicare
✓ Plan of Care
✓ Private Contract, Medicare, Provider Not Enrolled
✓ Proof of Delivery
✓ Standard Written Order
✓ Warranty, Complaint and After-Hours Care

Package 3: Patient Flow​​​​​​​

Package includes the flow of steps for the dental sleep patient:
✓ Flow Chart Undiagnosed Patient
✓ Flow Chart Diagnosed Patient

*Bundle all 3 packages for $500.00 – a savings of $50.00


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