Sleep Store
Are you an existing patient? Are you a new patient?
Once the selection is made, an insurance form is available for the patients to enter new information. Below you will find the information we need.
For new patients – please enter your insurance information.
For existing patients – Do you need to update your insurance with us?
Insurance portion:
Patient Information:
 
Insurance Information (Send Copy of Card)
         
Patient Name:
 

Company Name:

Address:
 

Policy Holder's Name:

City:
 

Policy Number:

State:
Zip Code:
 
Group Number:
DOB:
 

Phone:
Phone:
  
Employer:
Alt. Phone:
      
Measurements:
 

 

 
 

 

  
         
Physician:
Date:
Address:
Phone:
City:
Fax:
State:
   
 
 
Existing Patients - Please answer the following questions:
1.
How is your sleep with the machine?
 
2.
Are you using your machine every night?
 
3.
Are you having any problems at this time?
 
4.
Is your mask fitting without leaks?
 
5.
How many hours per night are you using your machine?
 
6.
Are you using the ramp setting to fall asleep?
 
7.
How are your tubing, water chamber, mask, headgear, and filters holding up?
 
I agree to share this information with Physician Diagnostics, LLC.
 
     
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Masks
Enter Quantity:
Fisher & Paykel Full Face CPAP Mask Silicone Seal
Fisher & Paykel Full Face CPAP Mask Foam & Silicone Seal
Fisher & Paykel Oracle 452 Oral Mask
Resmed Swift Nasal Pillows System with Headgear
ResMed Ultra Mirage II™ Mask with Headgear
Ultra Mirage™ Full Face Mask - MED
Ultra Mirage™ Full Face Mask - LRG
ComfortFull™ Full Face Mask with Headgear - MED
ComfortFull™ Full Face Mask with Headgear - LRG
 PD1004950
Respironics ComfortGel Nasal Mask (WITH HEADGEAR) - SM
Respironics ComfortGel Nasal Mask (WITH HEADGEAR) - MED
 PD1009042
Respironics ComfortGel Nasal Mask (WITH HEADGEAR) - LRG
ComfortLite 2 Mask Combo with Headgear - SM
ComfortLite 2 Mask Combo with Headgear - MED
 PD1030495
Fisher & Paykel Infinity Direct Nasal Mask and Headgear
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Mask Replacement Equipment
Enter Quantity:
Fisher & Paykel Flexifit Mask Replacement Foam & Silicone Seal
FlexiFit Series Full Face Mask w/Headgear - MED
FlexiFit Series Full Face Mask w/Headgear - SM
 PD400HC103
Fisher & Paykel Forehead Pad Replacements - 2pk.
Resmed Swift Replacement Pillows - SM
Resmed Swift Replacement Pillows - MED
 PD60521
Chin Strap
Respironics Comfort Gel Replacement Cushion - MED
Respironics Comfort Gel Replacement Cushion - SM
 PD1009049
Comfortlite 2 Replacement Nasal Pillows - SM
Comfortlite 2 Replacement Nasal Pillows - MED
 PD1030504
Comfortlite 2 Replacement Nasal Pillows - LRG
ComfortLite and Comfortlite 2 Simple Cushion Seal - SM
ComfortLite and Comfortlite 2 Simple Cushion Seal - MED
 PD1021823
ComfortLite and Comfortlite 2 Simple Cushion Seal - LRG
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Machine Replacement Equipment
Enter Quantity:
ResMed Machine Filters (3 Per Pack)
Replacement Water Chamber for all HC200 & HC220 Series CPAPs
Fisher & Paykel Replacement Chamber for the 600 Series
6' standard tubing to connect chamber to nasal mask. Includes 2 connectors.
Fisher & Paykel Machine Filters For HC220
Fisher & Paykel Machine Filters For HC240
 PD900HC240
Once your order is placed you will be contacted by one of our representatives.
 
 
 

Physician Diagnostics will not share or sell your personal information.
See our Terms & Conditions page for additional information.