CPAP ASSISTANCE PROGRAM
● 524 Craig Ave., Tracy, MN 56175 ● Fax 888-293-3650 ● Telephone: 888-293-3650 ●
● www.sleepapnea.org ● firstname.lastname@example.org ●
Complete this form and click submit, please make sure you pay the program fee and send your prescription. You will receive a confirmation of shipment and tracking number to the email address you indicate below.
By submitting this application, you hereby authorize the American Sleep Apnea Association (ASAA) to dispense the prescribed equipment package that you request below. The equipment package consists of continuous positive air pressure machine, tubing, filter, carrying case, and patient and/or clinician manuals. No humidifier is provided in the CAP equipment package. A mask is considered extra to the package and is not guaranteed. Please select a mask style and size on the form and we will include if we have your choice in our inventory. At this time, we have no BiLevels in our inventory and a limited supply of AutoCPAPs. The equipment package is offered “as is” and without warranty or technical support from the manufacturer. The ASAA does provide a 30-day warranty in the event the device is damaged during shipment or has a mechanical failure and will replace the machine for free.
The ASAA provides no CPAP set up, no instruction on device use, mask fit nor follow up care. If you require these services, we will ship to the office or agency you direct below who will provide these services. Otherwise, authorization to ship directly to the patient may be indicated below. $100 program fee per equipment package must be paid prior to shipping. This defrays program costs and allows us to help others.