Our customers come first request your supplies today. CPAP & Incontinence Refill Request Please fill out the refill request form below to begin the process of refilling your CPAP supplies. Contact InformationName(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Email(Required) Date of Birth(Required) Month Day Year Insurance InformationPlease allow 48 hours to process your refill request. We will contact you to confirm your insurance information. Customers w/Medicare Medicare determines the frequency at which you can receive certain items. These timeframes are in parenthesis below under the Refill Information section. Medicare requires an annual office visit with your physician or medical practitioner and an indication of your use and benefit of PAP therapy must be documented in this visit. A copy of this document must be on file with our company as well. Customers w/Commercial Insurance We can bill most insurance carriers and they will typically cover these items every 6 months. A representative from our office will determine what you are eligible for based on your plan. All Insurance You will be responsible for any deductible or co-pay before we bill your insurance.Has your insurance changed since your last refill?(Required) Yes No What is your new insurance?(Required)Refill InformationHow would you like to receive your refill?(Required) Pick Up Delivery When would you like to pick up your refill?(Required) Month Day Year Would you like to refill all your eligible supplies today?(Required) Yes, please send me all supplies that I am eligible for and that my insurance will cover at this time. No, please just send the below checked items. What supplies need to be refilled?(Required)Please select all that apply. Full Face Mask (1 every 3 months) Full Face Mask Cushion (1 every month) Nasal Mask (1 every 3 months) Nasal Mask Cushion (2 every month) Nasal Pillow (2 every month) Headgear (1 every 6 months) Chinstrap (1 every 6 months) Flex Tubing (1 every 3 months) Disposable Filters (2 every month) Reusable Filters (1 every 6 months) Other Concerns* This information pertains exclusively to CPAP prescription refills.Untitled I am interested in a new mask. Please contact me to schedule an appointment with a clinician. I am having trouble with my CPAP/Bi-Level machine. Please contact me for additional education. Additional Comments, Concerns, or InstructionsCAPTCHAPlease answer the math challenge.
