Supply Replenishment Authorization Form Name * Contact Information Primary Phone * Email * Address * City * ZIP * Supplies for use with your CPAP or BiPAP device play a vital role in your ability to remain compliant with your therapy, thereby receiving the maximum therapeutic benefit and reducing the long term health risks. Mask leaks can develop over time with continuous use and repeated cleaning, therefore, monthly replacement of cushions is recommended. Most insurances follow Medicare guidelines for replacing these medically necessary supplies as follows: Every Six Months Complete mask with headgear filters, non-disposable chin strap Every Three Months 6 ft. corrugated tubing Every Month Mask cushions and disposable filters All supplies dispensed as per insurance guidelines PLEASE NOTE: CPAP/BiPAP Manufacturers may void the device warranty if internal damage/failure is due to the filters not being changed as per their recommendations. If water damage causes the device failure due to improper handling or moving when the water chamber is full and attached, the warranty may be void. Please select your resupply option: * Choose hereAll supplies as recommended per insurance guideline3-Month Resupply6-Month ResupplyCustom (Please Specify) Other Resupply Option MEDICARE RECIPIENTS, PLEASE BE AWARE: In accordance with medicare rules, by your signature below, you are disclosing that there are no disposable supplies remaining and that you use your PAP device every night. * PRIVATE INSURANCES: Insurance co-pays and account balances can be charged to your debit/credit card as per the credit credit card payment agreement. * By signing below, you agree to be charged for insurance co-pays and account balances per the credit card payment agreement. Digital Signature *
Recent Comments