CPAP Supply Order Form

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Protect your Health.
Routine replacement of your CPAP supplies helps prevent the spread of bacteria and viruses. Breathe easier knowing your CPAP mask, tubing, and other supplies are clean and germ-free. Ensure you are receiving the greatest benefit from your therapy, and protect your health by filling out the order form below. American HomePatient will ship CPAP supplies directly to your home.

CPAP Supply Order Form

Your insurance provider may reimburse you for the cost of these items:

* = required field

Recommended Replacement Schedule
Schedule	Item	Qty.
2 per Month	Disposable Filter:
2 Sets per Month	Replaceable Pillow or Cushions:
Every 3 Months	Mask:
Every 3 Months	Tubing:
Every 6 Months	Chin Strap:
Every 6 Months	Headgear:
Every 6 Months	Humidification Chamber:
Every 6 Months	Non-Disposable Filter:

Have you ever ordered from American HomePatient before?

Customer Information
Full Name: *
Street Address: *
City: *
State: *
Zip Code: *
Phone:
Email: *

American HomePatient Location
If applicable, please provide the city and state of the American HomePatient location currently serving you:
City:
State:

Comments

Thank you! As an alternative to submitting an electronic message, you may contact us by phone, toll free, by calling: 1-877-221-8763.

Completing this form does not constitute an order.
An American HomePatient Representative will contact you within 2 business days regarding your comment.

Print and complete our Assignment of Benefits form

*American HomePatient must verify insurance coverage of any item(s) ordered before shipping to patients.

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