What is your first name? *

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What is your phone number? *

What is your zip code? *

Have you completed a Sleep Study? *

Thanks for the info, {{answer_19531502}}! If you have your insurance card handy, you can complete your sign-up right now online. *

If you would prefer to speak to one of our insurance specialists directly, submit your form now and we will be in touch to help you with the rest of the process.

What is the Member or Subscriber I.D. number on your insurance card? *

If you have Blue Cross/Blue Shield insurance, please include all of the letters and numbers in your ID (example: XYZ123456789).
What is your Date of Birth? *

Almost there! Just a few more questions because you indicated your insurance carrier as "Other PPO."

What is the full name of your insurance company? *

What is the phone number for Provider Services from your insurance card? *

This toll-free phone line may also be listed as "Benefits and Eligibility." If you can't find it, please put any customer service number that you can find. 

Last question! Are there any particular products that you are interested in?

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Easy Breathe is unable to work with your Medicare plan or Medicare supplement.    

Over 20,000 of our customers are eligible for Medicare. Even though we can’t bill Medicare, CPAP users like you prefer the convenience and customer service that Easy Breathe provides. We offer all the most popular supplies, such as CPAP masks, without a prescription. We also offer a 15% off coupon code to all of our Medicare patients: just enter the code MED15 at checkout.    

If using your Medicare coverage is the most important thing for you, we want to help. Check your email for our free Medicare Information Packet, which will have information on how to get your supplies covered by Medicare, and additional coupons if you decide to go with Easy Breathe after all.
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Thanks for completing our contact form, {{answer_19531502}}!
We will contact your insurance company to verify your coverage and will get back to you as soon as possible.
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