Request New Supplies

Use this form to request new supplies.

Please be aware that CPAP equipment requires a written prescription from the physician.
The doctors will not write prescriptions unless you are current with your appointments.
If you have not seen our doctor in the last 12 months please call and make an appointment.
You may be able to get your new supplies or a prescription for them at that same appointment.

Availability of CPAP supplies is dependent upon current insurance authorizations and you may be responsible for deductibles or co-payments mandated by your insurance plan.

** We now offer an automatic 90 day re-supply program with free shipping. Check the appropriate box in the form below to get more information or to be automatically enrolled in the program. **

Please complete the form below. Mandatory fields marked *

My Mask is a:

If you need CPAP supplies in addition to your mask, please indicate the type of CPAP machine you have and check the appropriate box(es) below:

I need 6 ft tubing and filters for my CPAP machine.
I need a new water chamber for my CPAP machine.
 

I would like more information on the automatic 90 day re-supply program.
I want to be automatically enrolled in the 90 day re-supply program.

If you are not enrolled in the 90 day auto re-supply, you can still have your supplies mailed to you if your insurance authorizations are current and the postage fee is prepaid. You are responsible for any deductible or co-pay mandated by your insurance carrier.
Check the box below if you would like to be contacted to make a payment by phone.
Please contact me -- I want to make payment by phone.
  Best Contact Number

 

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