CPAP Resupply Form

Contact Information

Name

Phone

Email

Date of Birth

Address

Address Line 2

City

State

Zip

Was there an Insurance Change?

Was there an Insurance Change?

Yes No

Insurance:

When would you like to pick up your order?

Date

Time

Please allow 24 hours to process your order, or 2 days if order is placed on Sunday.

If your insurance has changed since the last time you received supplies, please contact a home medical representative from your respective location.

For those with Medicare insurance:
Medicare determines the frequency that you can receive certain items. Those time periods are shown below in parenthesis. Medicare requires an annual office visit with your physician or medical practitioner. An indication of your use and benefit of PAP therapy must be documented in this visit and a copy of this document must be on file with our company.

Customers with commercial insurance plans:
We can bill most insurance carriers and they typically will cover these items every 6 months. A representative from our office will determine what you are eligible for under your plan.

All insurance plans: You will be responsible for any deductible or co-pay before we can bill your insurance.

Please select the supplies that you would like to have refilled:

Other Concerns

Note or Special Instructions: