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General Info
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General Info
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Secondary Insurance
Would you like to add a Secondary Insurance?
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Secondary Insurance Provider
Secondary Insurance ID #
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Referring Physician
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Documentation
To better serve you, please submit the following:
1. Prescription (Required)
A copy of a prescription from your physician. In addition to your name and the requested equipment, it must include diagnosis and length of need. Must be signed by a physician.
File 1 (Prescription)
*
Accepted file types: pdf, Max. file size: 10 MB.
**PDFs Only**
2. Sleep Study: Baseline PSG
A copy of your original sleep study which diagnosed your sleep apnea. It may have been in a diagnostic facility, or a home sleep test (HST). Must be signed by a physician.
File 2 (Sleep Study: Baseline PSG)
Accepted file types: pdf, Max. file size: 10 MB.
**PDFs Only**
3. Sleep Study: Titration report
A copy of your titration sleep study report done in a diagnostic facility. Not all patients will have a titration. Must be signed by a physician.
File 3 (Sleep Study: Titration report)
Accepted file types: pdf, Max. file size: 10 MB.
**PDFs Only**
Notes
Please add any additional information. Things we’d like to know:
-If you received a machine previously, the date which it was provided
-If you want Quality DME to become your resupply provider, please provide us with the make and model of your current equipment
-If you have questions about your equipment, tell us what they are
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