PAP Supply Reorder

As a CPAP or BiPap user, supply replacement is very important to help maintain your comfort and compliance. Did you know that approximately 2.6 million warm, moist breaths pass through your tubing and mask each year? Even with proper cleaning, facial oils can impact your mask's seal over time. Filters lose their effectiveness and tubing can be damaged or accumulate harmful bacteria.

Changing your supplies regularly will not only help minimize risk of infection, but keep your mask fitting comfortably without leaks and your therapy device functioning well.

Most insurance plans will reimburse your Homecare Provider for the regular replacement of these items. Check with your health plan for individual reimbursement guidelines.

* indicates a required field.

First Name: *

Last Name: *

Date of Birth: *

Address: *

City: *

State: *

Zip Code: *

Phone: *

Email:

Physicians Name: *

Has your insurance changed in the past 12 months?

If Yes, New Insurance Name:

Policy Number:

Have you received supplies in the past 3 months?
If yes, you may not be eligible for supplies per your insurance companies guidelines

I would like to order a Mask:
Most insurances allow the replacement of a mask every 3 months

Are you experiencing a mask "Leak"? *

Is Mask broken in any way? *

I would like to order Cushions:
Most insurances allow the replacement of cushions every 3 months

Are your Cushions/Pillow torn or worn out? *

I would like to order a Chin Strap:
Most insurance companies allow replacement every 6 months

Is your Chin Strap stretched out? *

I would like to order Headgear:
Most insurances allow replacement every 6 months

Is your Headgear worn and stretched out? *

I would like to order Tubing:
Most insurances allow replacement every 3 months

Are you worried there may be a pinhole or other malfunction? *

Are you worried there may be bacteria that may cause you to become ill? *

I would like to order a Filter:

Are you worried there may be bacteria that may cause you to become ill? *

I would like to order a Humidifier Chamber:
Most insurance allow replacement every 6 months

Are you worried there may be bacteria in your humidity chamber that may cause you to become ill? *

Would you like to order the above supplies in order to maintain your CPAP compliance and optimal therapy?

I authorize Lincolnland Home Medical to process my request for CPAP supplies and bill my insurance per my request: *

Agree

Your order will be processed and shipped to your home. Our representative will contact you if you do not qualify for supplies per your insurance guidelines.

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