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- Insurance Verification Information -

Patient Information

Title:

First Name:*

Last:*

Middle

Address:*

City:*

State:*

Zip:* -

Phone:*

#

Email:*

Reconfirm Email:*

Date of Birth:* (MM/DD/YYYY) SSN:

* indicates a required field

Insurance Information

Is Medicare Your
Primary Insurance?

Y/N

Medicare ID:

Name of Other Insurance*

Policy/ID:*

Ins. Address:

Group#:

City: State:* Zip:

Phone:* Ext.

* indicates a required field

Physician Information

Physician's Name:

Address:

City: State: Zip:

Phone:

Ext. Fax:

* indicates a required field

Sleep Lab Information

Lab Name:

Phone: Fax:

Address:

City: State: Zip: -

* indicates a required field

Equipment Information

Do You Rent or Own Your CPAP? Rent Own
Questions or Comments

Patient Release

I hereby authorize CPAP Supplies Direct, Inc. (mysleepapnea.com) to request on my behalf insurance coverage eligibility from the above-indicated insurance company/companies. I further authorize the release of any information necessary to process such claims, including medical record information from a physician, sleep lab, or hospital as it pertains to the eligibility of insurance coverage or for the purpose of meeting a prescription requirement for the purchase of a respiratory device or supply item from CPAP Supplies Direct, Inc.(mysleepapnea.com). I further authorize CPAP Supplies Direct, Inc. (mysleepapena.com) to share the insurance eligibility information obtained from the insurance company with a preferred provider who is licensed and authorized.

I do not agree. I want to contact my doctor and sleep lab myself for any needed documents.	I agree. I want alertmedical.com to contact my doctor and sleep lab for any needed documents

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