PAP/CPAP Supply Order Form
To satisfy health care insurance guidelines, you must submit this form completely and accurately to confirm your continued need for CPAP/PAP supplies . Your responses will be used to process refills and ensure compliance. For questions, call or text us at 480-347-9190.
Email
If you would like a confirmation of your order submitted, please include a valid email.
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Patient Information
Date of Birth
*
-
Month
-
Day
Year
Date
Name (as appears on your insurance card)
*
If you are not the beneficiary, please provide your name and relationship to the patient.
Has your insurance changed since your last order?
*
Yes
No
Updated Carrier Name and Policy Number / Medicare Member Number
as it appears on your card.
Option to upload Insurance
add info
Drag and drop files here
Choose a file
Take a picute of the front and back of your insurance card
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of
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Address Information
Has your address changed since your last order?
*
Yes
No
Updated Address Information
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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CPAP/PAP Usage
Medicare Requirement Only
Are we billing Medicare for your supplies? If YES, please answer these 6 questions
Yes
No
Are you still using your CPAP/PAP machine for sleep apnea treatment?
*
Yes
No
On average, how many NIGHTS per week do you use your CPAP/PAP machine?
*
Worst
1
2
3
4
5
6
Best
7
1 is Worst, 7 is Best
On average, how many HOURS per night do you use your CPAP/PAP machine?
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Approximately how days left of current supplies do you have on hand?
*
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
Have there been any changes in your condition, equipment needs, or medications since your last refill?
*
Yes
No
Briefly explain any changes experienced from last refill.
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Do you want to repeat your last supply order?
Yes
No
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Select the refill supplies needed.
Select one mask.
Full Face Mask w/ Headgear
Nasal / Pillow Mask w/ Headgear
No mask needed
To ensure your order is accurate, please upload a picture of your current CPAP mask. This helps us confirm the correct style and size.
Browse Files
Drag and drop files here
Choose a file
Optional
Cancel
of
Cushions for Full Face Mask (1 per month) up to 3 per order
3
2
1
Cushions for Nasal / Pillow l Mask (2 per month) up to 6 per order
6
4
2
Select remaining supply needs.
Filters - Disposable 6-pack (2 per month)
Filter - Non Disposable (1 per 6 months)
Tubing - Standard (1 per 3 months)
Tubing - Heated (1 per 3 months)
Heated Humidifier Chamber (1 per 6 months)
Other
Other Needs / Comments
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Affirmative Confirmation Statement
I confirm that the information I have provided is accurate and that I require the requested refills to continue my CPAP/PAP therapy.
By selecting below, I agree that my responses are accurate and acknowledge this as my electronic signature.
*
Yes
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