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Insurance Intake & DME Form









Gender: Marital Status:
(MM/DD/YYYY)
 
INSURANCE:
*The Insured is the person who holds the insurance if different than the patient above.


Relationship to Patient:  






   
REFERRING PHYSICIAN:





 


   
Products to be ordered (check all that apply):  
E0471 BIPAP -ST PURCHASE
   

What is 3 plus 2?

 
   
By clicking the button below, I understand that CPAP Supplies Plus/Direct is collecting data for purposes of billing my health insurance for CPAP supplies and that the information provided will be used to determine my insurance coverage. I also understand that my cost for CPAP supplies will be determined by my benefits structure, insurance pricing schedules. I understand that CPAP Supplies Direct/Plus is in no way contracted with any insurance company, and therefore not bound by any contractual amount agreements. The prices of the listed equipment will not be changed based on my individual insurance coverage. I understand that I am financially responsible for all amounts not covered by my insurance company.
* I agree to terms.