Reorder CPAP Supplies

- Send me a new mask and tubing upon receipt of this form, or after 90 days since my last mask, whichever is later.

- I use my mask at least 4 hours every 24 hour period.

- I have used CPAP device for the preceding 2 months.

- I will continue my CPAP therapy.

- I acknowledge receiving my last shipment.

I am nearly exhausted of my supplies, and require that you send my next shipment of supplies when due. I acknowledge receiving the supplier standards, warranty info and training materials. I authorize the company to renew my prescription, to verify my insurance benefits, to contact me, to request and accept the release of my relevant medical records, and to submit claims and claim assignment of payments of medical benefits for items/services provided to me.