FULL FACE MASK Reorder Form

This reorder form is for FULL FACE MASK SUPPLIES ONLY.

Name Name First Last
Email
Phone Phone - ### - ### ####
Preferred method of contact

Preferred method of contact Email Phone
Date of birth Date of birth / MM / DD YYYY
Shipping address Shipping address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Has there been a change with your INSURANCE since your last order?

Has there been a change with your INSURANCE since your last order? Yes No
If there has been a change with your INSURANCE since your last order, please enter your new information below.
Has there been an ADDRESS CHANGE since your last order?

Has there been an ADDRESS CHANGE since your last order? Yes No
If there has been an ADDRESS CHANGE since your last oder, please enter your new information below.
Please choose 1 from below:

Please choose 1 from below: Order all my eligible supplies Order the selected supplies from the boxes below
REORDERING REQUEST - FULL FACE MASK

REORDERING REQUEST - FULL FACE MASK Complete FULL FACE MASK WITH HEADGEAR (can be replaced every 6 months) Replacement FULL FACE CUSHION ONLY (can be replaced every month)
REORDERING REQUEST - ALL OTHER ACCESSORIES

REORDERING REQUEST - ALL OTHER ACCESSORIES Replacement Tubing (can be replaced every 3 months) Replacement Filters (can be replaced 2 times per month) Replacement Water Chamber (can be replaced every 6 months) Replacement Chin Strap (can be replaced every 6 months)
REASON FOR YOUR REPLACEMENT SUPPLY REORDERS

REASON FOR YOUR REPLACEMENT SUPPLY REORDERS My supplies are dirty, torn, leaking and need to be replaced.
SHIPPING IS FREE
Other comments:
By checking the box below, I acknowledge the following:

• Only eligible supplies per my insurance guidelines will be shipped.

• I am actively using and benefiting from CPAP therapy.

• If there is a concern with my order Mercyhealth at Home HME will contact me before shipping my order.

• I have informed Mercyhealth at Home HME of any demographics or insurance changes or other factors that may impact my order (in the comment box above).

• I am responsible for any copays and charges levied by my insurance as a result of my order.

“I understand that the information I enter into this form will be transmitted and stored electronically. I further understand that although security safeguards are in place, no system is completely secure. The transmission and storage of this information still involves some privacy and security risk, which I agree to assume.”

By checking the box below, I acknowledge the following:

• Only eligible supplies per my insurance guidelines will be shipped.

• I am actively using and benefiting from CPAP therapy.

• If there is a concern with my order Mercyhealth at Home HME will contact me before shipping my order.

• I have informed Mercyhealth at Home HME of any demographics or insurance changes or other factors that may impact my order (in the comment box above).

• I am responsible for any copays and charges levied by my insurance as a result of my order.

“I understand that the information I enter into this form will be transmitted and stored electronically. I further understand that although security safeguards are in place, no system is completely secure. The transmission and storage of this information still involves some privacy and security risk, which I agree to assume.” I acknowledge I have read, understand and agree with the above and below statements.
I ACKNOWLEDGE RECEIPT OF EQUIPMENT AND/OR SUPPLIES ON THIS ORDER. I request that payment of authorized Medicare, Medical Assistance, and/or Medical Insurance Benefits be made either to me or on my behalf for any services furnished me by Mercy Assisted Care, including physicians services, on assigned claims. I hereby guarantee payments to Mercy Assisted Care of any and all charges not covered by this assignment, and waive any and all notices and demands in the event of non-payment there under. I authorize any holder of medical or other information about me to release to the Centers of Medicare and Medicaid Services and its agents any information needed to determine these benefits or benefits for related services.

For other questions, comments, or concerns, contact the CPAP resupply coordinator at 608-755-8732.

FULL FACE MASK Reorder Form

FULL FACE MASK Reorder Form

SHIPPING IS FREE