Service Request Form

Download our Service Request Form

(prescription form)

FILLABLE Service Request Form: You can download this version of the form and fill out the patient information, services requested, etc. on your computer. 

When you click the link, the form will display in your browser.  You can then download the form to your computer.

Download the FILLABLE Service Request Form here

NON-FILLABLE Service Request Form.  This form prints a little better than the fillable version, if you plan to fill out the form by hand. 

When you click the link, the form will display in your browser.  You can then download the form to your computer.

Download the NON-FILLABLE Service Request Form Here

Fax the completed form to (877) 855-6227 or email orders@sleepdr.com

• Home Sleep Testing (HST)
• CPAP Device Set-up
• CPAP replacement supplies

The form includes the CPT codes for services.

Use the link above (in the body of the post) to download the form