Provider Form

PRACTITIONER INFORMATION
Name

First NameLast Name
Practice/Organization
Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
NPI Number
PATIENT INFORMATION
Patient Name

First NameLast Name
Preferred Name
Date of Birth

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Member ID
Insurance State
This can be found on the back of your ID card.
Please select the age range of your patient.
Adults (18+) with:
Adolescents (13-17) with:
Diagnosed Conditions
If they have a diagnosis other than PTSD or Panic, please provide explanation:
Optional: Authorize your patient for Freespira treatment
Upload Medical Records associated to the diagnosis

Panic or PTSD assessment
Cancelof
I understand that, with my signature, I am authorizing (prescribing) the Freespira treatment (capnography-guided respiratory Intervention), and I have informed the patient to expect outreach from a Freespira representative for enrollment into treatment.

I am not aware of any contraindications or other reasons why the patient identified above should not, at this time, undergo the Freespira treatment. I agree that this signature may also be applied to a Certificate of Medical Necessity.
Lead source detail
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PDF sent
example@example.com
Should be Empty: