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Provide Your Information
Your Name*
First Last
Your Date of Birth*
E-Mail Address*
Phone Number*
Address*
Street Address City State ZIP Code

Provide Your Insurance Details
Insurance Policy Number*
Group Number
Insurance Company Name*
Insurance Phone Number
Doctor Name*
Doctor Phone Number

Sleep Apnea Questions
Have you completed a sleep test?*
- Yes
- No
To get a CPAP machine through insurance, a sleep test is required. Are you interested in getting a sleep test?*
- Yes
- No
Do you own a CPAP machine?*
- Yes
- No
If yes, what year did you receive your current CPAP machine?
When was the last time you ordered CPAP supplies through your current insurance?
CPAP Supplies includes items such as CPAP masks, cushions, tubing and filters.
Check the products you need (check all that apply):
- CPAP Machine
- CPAP Mask
- CPAP Supplies
Authorization*
- I agree to the terms & conditions and to sign electronically.
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For assistance with ordering CPAP products through insurance, contact our customer service team at 888-510-5100.

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