CPAP Supply Order

CPAP Supply Order Form

Easily and conveniently order your CPAP supply below! Once you place your order, it will be sent to your preferred pharmacy location. Our medical equipment specialists will gather your information and contact you.

1 Your Information

2 Supplies Needed

3 Insurance

4 Location

5 Review

Patient Name*
(Full legal name or as printed on the insurance card)
First Last
Email*
Enter Email Confirm Email
Home Phone
Mobile Phone
Date of Birth*
Preferred Method of Contact*
How would you prefer us to contact you?
- Home Phone
- Mobile Phone
- Email
Have you ordered CPAP supplies from us before?*
- Yes
- No
Has your address changed since your last order?*
- Yes
- No
Has your insurance changed since your last refill?*
- Yes
- No
Address*
Street Address City State ZIP Code

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CPAP Supplies*
- CPAP Headgear
  Insurance allows 1 (one) CPAP headgear every six months.
- CPAP Mask
  Insurance allows 1 (one) CPAP mask (full face or nasal) every 3 (three) months.
- CPAP Cushion
  Insurance allows 1 (one) CPAP full base cushion or 2 (two) CPAP nasal cushions or pillows per month.
- CPAP Tubing
  Insurance allows 1 (one) CPAP tubing every 3 (three) months. We offer tubing to fit Phillips Respironics Respironics Dream Station, System One CPAP machines, and ResMed machines. We do not bill insurance if tubing is the only supply ordered.
- CPAP Disposable Filters
  Insurance allows 2 (two) CPAP Disposable Filters per month. We offer filters for Phillips Respironics Dream Station, System One CPAP machines, ResMed machines, and Luna CPAP machines. We do not bill insurance if CPAP Disposable Filters are the only supply ordered.
- CPAP Non Disposable Filters
  Insurance allows 1 (one) CPAP Non Disposable Filter every 6 (six) months. We offer filters for Phillips Respironics Dream Station, System One CPAP machines, ResMed machines, and Luna CPAP machines.
- CPAP Water Chamber
  We do not bill insurance for CPAP water chambers, these are cash items. We offer both Phillips Respironics Dream Station and System One brand water chambers.
- CPAP Chin Straps
  We do not bill insurance for CPAP chin straps, these are cash items.

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Primary Insurance
Primary Insurance
ID #
Group # / Plan
Policy Holder Name
(as printed on the insurance card)
Insurance Effective Date
Date of Birth
Secondary Insurance
Do you have a secondary insurance?
- Yes
- No
Secondary Insurance
ID #
Group # / Plan
Policy Holder Name
(as printed on the insurance card)
Insurance Effective Date
Date of Birth
Beneficiary relationship to policy holder
- Owner
- Spouse
- Child
Employer Information
Employers Name
Employers Address
Street Address City State ZIP Code

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Select location for pickup*
- Lewisport
  8180 US Hwy 60 West
  Lewisport, KY 42351
  Phone: (270) 295-3131
- Central City
  102 West Broad St.
  Central City, KY 42330
  Phone: (270) 754-1545
- Owensboro
  2200 East Parrish Ave.
  Owensboro, KY 42303
  Phone: (270) 926-6260
- Greenville
  159 South Main St.
  Greenville, KY 42345
  Phone: (270) 338-6060
- Livermore
  311 Highway 431
  Livermore, KY 42352
  Phone: (270) 278-5537

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Name	{Patient Name (First):1.3} {Patient Name (Last):1.6}
DOB	{Date of Birth:2}
Address	{Address (Street Address):3.1} {Address (City):3.3}, {Address (State / Province):3.4} {Address (ZIP / Postal Code):3.5}
Today's Date	04/17/2021
Preferred Method of Contact	{Preferred Method of Contact:7} -

Our staff in {Select location for pickup:40:value} will look at your chart to order the correct supplies.

Please review the supplies you are requesting to be refilled before submitting this request: {CPAP Supplies:13:value}

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CPAP Supply Order Form

CPAP Headgear

CPAP Mask

CPAP Cushion

CPAP Tubing

CPAP Disposable Filters

CPAP Non Disposable Filters

CPAP Water Chamber

CPAP Chin Straps

Primary Insurance

Secondary Insurance

Employer Information

Lewisport

Central City

Owensboro

Greenville

Livermore

Our staff in {Select location for pickup:40:value} will look at your chart to order the correct supplies.

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