CPAP Supply Order Form
    Phone: (800) 545-6026
Fax:     (800) 545-6071
 

CPAP Supply Order Form

First Name:
Last Name:
Address:
Daytime Phone:
Email Address: 

Please check the items you would like to order:

CPAP Mask & Headgear
Same Mask Model & Size as Last Order
Tubing (Standard 6 foot)
Tubing (8 ft)
Extra Cushions
Disposable Filters
Washable Foam Filter
Chin Strap
Humidifier water chamber


For patients with CAREFIRST insurance, please enter the number of hours per night and days per week you use your machine:

Hours per night used:
Nights per week used:

For patients with MEDICARE, please check the reason that you are requesting replacement supplies (required by Medicare):

My equipment is dirty and can not be cleaned.
My equipment is broken and not repairable.
My mask will not adequately seal due to wear.
My headgear is stretched leading to a poor mask seal.
I am having other issues with my current equipment.

Description or Comments:
 

Additional Accessories Requested:
 

Please check the information that has changed since last order:

My address has changed
My insurance policy has changed
My ordering physician has changed
My prescription has changed

Please describe the changes:
 

In the future, I would like to be part of the Automatic Re-Supply Program.  I want to receive supplies when my insurance will cover their portion.  I understand that I will be responsible for any copay, coinsurance or deductible. I also understand that I can opt out of automatic delivery at any time by emailing info@ahcah.com or calling our office at (800) 545-6026.


  
 

Medicare and most other insurances will cover the cost of replacement supplies as follows:


Every 3 Months:

  • Mask with cushion
  • Additional Nasal Cushions or Pillows: 2 per month
  • Additional Full Face Mask Cushions: 1 per month
  • Tubing
  • Disposable Filters: 2 per month

Every 6 Months:

  • Headgear (straps)
  • Reusable foam filters
  • Chin Strap
  • Humidifier water chamber

See other Accessories for CPAP therapy

(not covered by insurance)