CPAP / BiPAP Supplies Order Form

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Sex *
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. *
 
IS THERE ANYTHING WRONG WITH YOUR CURRENT EQUIPMENT? *
 

Insurance

Equipment Information

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

 

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. *