REORDER SUPPLIES

SUPPLY REORDER CHECK LIST

Patients Name*

Please enter your full name

Email*

Phone Number*

Other Phone Number

Most insurance companies follow standard guidelines for replacing your CPAP supplies. Replacing your CPAP supplies as directed helps prevent infection, increases effectiveness of therapy, and improves comfort. Please select the supplies you require below; if you are ineligible for any supplies you requested, we would contact you before sending them out.

PLEASE SELECT YOUR SUPPLIES

Insurance Code - Description - [Frequency allowed by most insurance companies]

OPTIONAL ACCESSORIES

Have you changed your address?

NO
YES

My new address is:

Street Address Address Line 2 City State ZIP Code

Have you changed your insurance?

NO
YES

Name of Insurance company

ID number

Group Number

Subscriber Name

Special Instructions

By placing this order I certify that the information given by me is correct. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for covered services rendered by Advanced Sleep Therapy, Ltd. to Advanced Sleep Therapy Ltd. and authorize Advanced Sleep Therapy Ltd. to submit claims to Medicaid and commercial insurance carriers for payment. I authorize payment of my insurance benefits directly to Advanced Sleep Therapy Ltd. which may not exceed the balance due on my account. I hereby guarantee payment to Advanced Sleep Therapy Ltd. of any and all charges not covered by this assignment, and waive any and all notices and demands in the event of non-payment there under. I am aware that Advanced Sleep Therapy Ltd. will bill me for my deductible and co-pay charges on equipment and/or supplies that I have rented or purchased. If my insurance denies payment, I agree to be personally and fully responsible for payment. I agree to pay any fees associated with collections if I fail to pay my bill in 90 days or make payment arrangements if payment in full is not possible.

Phone

This field is for validation purposes and should be left unchanged.

REORDER SUPPLIES

EXISTING PATIENTS MAY ORDER SUPPLIES HERE 24/7