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We accept

We are Here to Help You Bill Your Health Insurance for your Out-of-Pocket Equipment & Supplies

Insurance Claim Form


I understand that Sleep Restfully, Inc. is accepting me as a private pay patient and I will be responsible for paying for any services or products that I receive. I understand that Sleep Restfully, Inc. will not file a claim to Medicaid, Medicare, or any other third party payor, for the equipment and/or supplies that are provided to me.

We are always glad to provide an invoice and other information so you may bill your insurance carrier. This will not constitute the acceptance of assignment or the acceptances of your insurance company's approval amount as our payment amount.  Any payment made to, at the time of sale constitutes the final payment amount accepted by you the customer. You are required to pay the full cash sale price of the equipment prior to shipment.  Any and all arrangements between a customer and their 3rd party payers remains between those parties and is outside of any transaction with  You are responsible for the total sale price charged.

To assist you in the completion of your insurance claim form we are providing general instructions for the completion of this form along with a downloadable and printable insurance claim form with information on Sleep Restfully, Inc. prefilled.  We cannot guarantee that your insurance company will accept your claim and the amount if any that you will be reimbursed. Please contact your individual insurance company to assist in the determination of any benefits due.

Items usually required by insurance company along with claim form:

  • Invoice for the merchandise purchased.
  • A copy of your prescription and/or letter of medical necessity.

Items which must be completed on your claim form:

  • All patient information and health plan information.
  • Signature of patient and date completed.
  • Diagnosis code. This can usually be found on your prescription or sleep study or you may contact your physician's nurse for this information.
  • Name of physician and his NPI number. The NPI number is usually on prescription or may be obtained from physician's office.
  • HCPCS Codes.  You will find the most common codes on our site under "Insurance Billing Codes"  or click HERE

If you have any questions concerning the completion of your claim form we suggest you contact your insurance carrier prior to sending the form in order to avoid having to resubmit it.

Download Claim Form and Instructions with Sleep Restfully completed information by clicking HERE

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Sleep Restfully, Inc.
3100 Weslayan Street, Suite 373
Houston, TX 77027
(866) 923-2727
(281) 840-4504
Fax:(800) 540-5078
(281) 501-7969

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