Your medical provider has ordered a home sleep test for you. To receive your test, please complete the Registration Form below.

Before getting started, you may visit our website to learn about Snap Diagnostics’ home sleep test and to view our privacy policy.

Upon completing your registration, Snap Diagnostics will send a sleep test kit to your indicated address. Typically your order will be processed within one business day, and you will receive notification when your test kit has shipped. Follow the instructions provided in the kit, or on our website, to complete your sleep test. Your results will be sent to your physician after you return the test kit to Snap.

Patient Details

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Your email is only used in efforts to reach you for your medical procedure
Please only provide an address where you are certain that a package addressed to you will be received.
Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing
Sitting and reading
Watching television
Sitting inactive in a public place (for example, a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

Health Insurance Details

The answer to this question is "No" if you are enrolled in a Managed Medicare program through a commercial insurance company.
Optional - only use if necessary to send additional information not provided elsewhere on this form. Please upload only one file for this option.

Patient Payment Details

Patients covered by insurance will typically have a small out of pocket cost. If you wish to provide your HSA or FSA card for payment, please call our customer support at (800) 762-7786 for assistance. We still require a debit or credit card to ensure the return of the testing device within the time frame agreed upon below.
Your credit card information is encryped and stored securely to protect you from fraudulent use on a PCI compliant server. Internal Snap employees do not have access to, or visibility of, your credit card information. Any charges will show as "SNAP DIAGNOSTICS" on your credit card statement.

Important Details about Your Home Sleep Test

Please call Snap Diagnostics at 800-762-7786 if you are unable to complete the sleep test within seven days of receiving the test kit. Alternatively, you are agreeing to the following: If I do not return the Snap recorder to approved location within seven (7) days, by my signature below I authorize SNAP Diagnostics to charge the credit card provided above a fee of $500 to cover the expense of the recorder. If the recorder is returned to Snap, the failure to return charge will be credited back to my credit card. I also understand that on rare occasions an insurance provider may elect to issue the payment directly to a patient. I agree that I will forward to Snap Diagnostics the amount of any payment sent to me by my health insurance plan for the Snap Home Sleep Test within 10 days of receipt of that payment. If I fail to send the payment to Snap, within ten days of Snap notifying me of this rare event, I agree that Snap can charge my credit card on file for the amount I was reimbursed by the insurance provider for the Snap Home Sleep Test.
Patient Assignment of Benefits and Release Authorization. In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to SNAP Diagnostics, LLC (SNAP) all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered by SNAP. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize SNAP to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to SNAP any and all plan documents, insurance policy and/or settlement information upon written request from SNAP in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions. I hereby convey to SNAP to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from SNAP and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with SNAP in any attempts to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses. Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA, ERISA, Medicare and applicable federal or state laws. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement. I acknowledge SNAP diagnostics is releasing a Sleep Test Recorder to my possession and that the Recorder is property of SNAP Diagnostics. I have been trained on the use of the SNAP equipment by video, person or written form. I have received a copy of the Notice of Privacy Practices.

What is 6 + 8?

Tip: If you are enrolled in Medicare for your primary insurance you will need to provide your Medicare Number.

Your Medicare Number will be shown on your red, white and blue Medicare card. An example Medicare card is pictured below. 

If you are enrolled in a Medicare Advantage Plan (HMO or PPO), your Medicare Advantage Plan ID card is your main card for Medicare. Your Medicare Advantage Plan card will vary in appearance based on the commercial insurance carrier. 

If you are enrolled in a Medicare Advantage plan, then the answer to the question about Medicare as your primary insurance is “No.”

Need Help?

Call: 847-777-0000

email: Support@SnapDiagnostics.com