Qualify Through Insurance

Discover Your Insurance-Covered Nebulizer and Kit Options! Simply enter your information below to find out which nebulizers and kits you qualify for through your insurance plan.

NOTE: Do not use this form in case of an emergency. Contact your physician for any medical questions or problems you may have.

Patient's Name*

First Last

Parent/Guardian Name (If Applicable)

First Last

Patient's Date of Birth*

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Insurance Name*

Insurance ID Number*

Insurance Card Front Image

Accepted file types: jpg, png, pdf, Max. file size: 5 MB.

Insurance Card Back Image

Accepted file types: jpg, png, pdf, Max. file size: 5 MB.

Please select the option that best fits:

Nebulizer kit including compressor, cup, tubing, mask, and filters

Replacement supplies including cup, tubing, mask, and filters

Compressor replacement

Prescription Upload – Required for all new equipment requests

Accepted file types: pdf, jpg, Max. file size: 5 MB.

Please upload a PDF of your prescription, if available.

If you do not have a prescription and would prefer Neb Medical to request one for you, enter your doctor's information below. We cannot guarantee your provider's cooperation but a team member will provide status updates.

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