Submit Your Information for Insurance Processing

If you would like CPAP supplies and prefer to use your insurance, please fill out the form below. A BetterNight Resupply Specialist will review your information and contact you to assist with processing your insurance. If you would prefer to pay cash for your CPAP supplies today, please click here.

Rest assured, your personal information will remain private and secure. It will only be reviewed by our trusted BetterNight professionals to assist with your CPAP supply needs. We are committed to maintaining the highest standards of confidentiality.

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Provider

Insurance Policy Number

Insurance Group Number (if applicable)

What CPAP supplies are you interested in?

Any Additional Comments/Questions

Submit Your Information for Insurance Processing

Thank you!