Bill My Health Insurance

To determine if we can bill your health insurance for your CPAP therapy needs, please complete the following form. We will contact you after the form in received and your coverage is verified. Please remember that we have secured the transmission of all data through our site, so your sensitive patient information will be safe. Please view our Security/HIPAA Compliance page for more information. Contact us directly at 1-866-994-BMHI(2644) for more information.

Full Name:

Email Address:

Phone Number:

DOB:

Gender:

Best Time to Contact:

Primary Insurance Company:

Policy Number (Primary Insurance):

Primary Policy Type:

Secondary Insurance Company:

Policy Number (Secondary Insurance):

Secondary Policy Type:

CPAP Products in which you are interested (Optional):
Machine:

Mask:

Accessories:

Model name of product in which you are intereded (if known):

Other Questions and Comments:

Coverage Verification Form