PAP Supplies Reorder

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• Name*
• Insurance*
• Email *
• Phone *
• Address
• City
• State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Zip
• Are you a Medicare beneficiary? Yes No

• Please check the items you want to order:*

  Supplies

  Mask with Headgear
  Disposable Filter
  Chinstrap
  
• Supplies

  Mask Seal/Pillows/Cushion
  Tubing
• Supplies

  Durable/Washable Filter
  Water Chamber
  

• Mask

  Mask

  Worn
  Broken
  Not Cleanable
  Other (describe below)

• Headgear

  Headgear

  Stretched
  Torn
  Other (describe below)

• Seals/Cushions/Pillows

  Seals/Cushions/Pillows

  Leaking
  Torn
  Other (describe below)

• Filter Filter (Washable)

  Filter (Washable)

  Worn
  Torn
  Other (describe below)

• Filter (disposable)

  Filter (disposable)

  Dirty
  Other (describe below)

• Tubing

  Tubing

  Not Cleanable
  Cracked
  Other (describe below)

• Water Chamber

  Water Chamber

  Not Cleanable
  Cracked
  Moldy/Cloudy
  Other (describe below)

• Chinstrap

  Chinstrap

  Stretched
  Torn
  Other (describe below)

• Authorization

  Authorization

  Please send 3 month supply of product if allowed by insurance
  I authorize detailed communication about my order via e-mail, text, and/or voice mail
  I understand that all supplies are subject to deductible and co-insurance, and agree to pay my responsible amount*
• Additional Comment
• Electronic Signature*