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. 1Your Information2Supplies Needed3Insurance4Location5Review Patient Name(Required)(Full legal name or as printed on the insurance card) First Last Email(Required) Enter Email Confirm Email Home PhoneMobile PhoneDate of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Preferred Method of Contact(Required)How would you prefer us to contact you? Home Phone Mobile Phone Email Have you ordered CPAP supplies from us before?(Required) Yes No Has your address changed since your last order?(Required) Yes No Has your insurance changed since your last refill?(Required) Yes No Address(Required) Street Address City 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 State ZIP Code CPAP Supplies(Required) CPAP HeadgearInsurance allows 1 (one) CPAP headgear every six months. CPAP MaskInsurance allows 1 (one) CPAP mask (full face or nasal) every 3 (three) months. CPAP CushionInsurance allows 1 (one) CPAP full base cushion or 2 (two) CPAP nasal cushions or pillows per month. CPAP TubingInsurance 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 FiltersInsurance 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 FiltersInsurance 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 ChamberWe 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 StrapsWe do not bill insurance for CPAP chin straps, these are cash items. Primary InsurancePrimary Insurance ID # Group # / Plan Policy Holder Name(as printed on the insurance card) Insurance Effective DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Secondary InsuranceDo you have a secondary insurance? Yes No Secondary Insurance ID # Group # / Plan Policy Holder Name(as printed on the insurance card) Insurance Effective DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Beneficiary relationship to policy holder Owner Spouse Child Employer InformationEmployers Name Employers Address Street Address City 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 State ZIP Code Select location for pickup(Required) Lewisport8180 US Hwy 60 WestLewisport, KY 42351Phone: (270) 295-3131 Central City102 West Broad St.Central City, KY 42330Phone: (270) 754-1545 Owensboro2200 East Parrish Ave.Owensboro, KY 42303Phone: (270) 926-6260 Greenville159 South Main St.Greenville, KY 42345Phone: (270) 338-6060 Livermore311 Highway 431Livermore, KY 42352Phone: (270) 278-5537 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 02/07/2023 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} Δ