CPAP Supply Order

1Your Information

2Supplies Needed

3Insurance

4Location

5Review

Patient Name(Required)

(Full legal name or as printed on the insurance card)

First Last

Email(Required)

Enter Email Confirm Email

Home Phone

Mobile Phone

Date of Birth(Required)

Preferred Method of Contact(Required)

How would you prefer us to contact you?

Home Phone

Mobile Phone

Have you ordered CPAP supplies from us before?(Required)

Yes

Has your address changed since your last order?(Required)

Yes

Has your insurance changed since your last refill?(Required)

Yes

Address(Required)

Street Address City State ZIP Code

CPAP Supplies(Required)

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.

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

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

Select location for pickup(Required)

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

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	05/28/2022
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}