CPAP / BiPAP Supplies Order Form

If you are just looking for information and not ready to place an order please click here.

Are you a NEW Patient? *

Date of Birth (MM/DD/YYYY) * +

Last Name *

First Name *

Middle *

Social Security Number *

Sex *

Male

Female

Weight *

Height *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Alternate Number

Email Address *

Any changes to your Insurance? *

Have any changes been made to your Secondary Insurance? *

Do you currently have a CPAP or BiPAP Machine? *

PLEASE CHECK OFF EACH ITEM YOU WISH TO RECEIVE IN YOUR ORDER. PLEASE NOTE: MOST INSURANCE COMPANIES WILL PAY FOR A MASK, TUBING, AND DISP FILTERS EVERY THREE MONTHS, AND WILL NOT CONSIDER HEADGEAR, REUSABLE FILTERS, OR A HUMIDIFIER CHAMBER UNTIL SIX MONTHS. *

CLICK HERE TO SEE A SCHEDULE FOR SUPPLIES THAT MOST INSURANCE COMPANIES FOLLOW

IS THERE ANYTHING WRONG WITH YOUR CURRENT EQUIPMENT? *

DO YOU HAVE ANY REMAINING SUPPLIES FROM PREVIOUS ORDERS? IF YES PLEASE LIST THE ITEM AND QUANTITY. IF NO PLEASE ENTER "NO" OR "0" IN THE FIELD BELOW. *

Insurance

Enter name of your Primary Insurance company *

Policy Holder *

Policy Number *

Group Number *

Address and Phone Number on Back of Insurance Card *

Do you have a secondary insurance? *

Please enter name of Secondary Insurance company *

Policy Holder *

Policy Number *

Group Number *

Address and Phone Number on Back of Insurance Card *

Equipment Information

What year was your CPAP/BIPAP setup? *

What company supplied your machine? *

Does your machine have a humidifier? *

Is your humidifier Heated or Cooled? *

What is make/model of your CPAP/BiPAP Machine? *

Respironics P-Series

Respironics M-Series

RemStar Plus

Other Other

What mask are you using? *

Serial number of CPAP/BiPAP

What sleep lab performed your sleep study?

Who was the physician that ordered your machine?

Did Insurance pay for your machine? *

Is this the Insurance that paid for your machine (current Insurance)? *

Is your machine in working order? *

Please list problems you are having with your machine. *

If you have copies of paperwork that you would like to upload you may do that here. You may also fax them to us toll free at 1-866-930-1360.

Order Supplies

I would like for Absolute Medical Equipment to send me the supplies that I qualify for through my insurance policy. I understand that by submitting this form that my insurance will be billed and I am responsible for any copays, deductibles and shipping charges. *

I agree

I disagree

Please Type Your Name in the box *