Supply Replenishment Authorization Form

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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.

By signing below, you agree to be charged for insurance co-pays and account balances per the credit card payment agreement.