CPAP Mask/Supply Application
CPAP ASSISTANCE PROGRAM
524 Craig Ave., Tracy, MN 56175 ● Fax 888-293-3650 ● Telephone: 888-293-3650 ● www.sleepapnea.org ● firstname.lastname@example.org
Due to a large donated supply of ResMed Quattro FX Full Face masks, Philips Respironics Amara Gel full-face masks and several other donated factory sealed masks and supplies from other donor’s we are able to provide our members and patients a significant cost saving opportunity to stock up for the year. This offer includes ResMed Quattro FX Full Face masks with headgear in your choice of medium or large; the Philips Respironics come with 2 headgear sizes, and 4 cushion sizes petite, small, medium and large; Respironics medium wide Full Face mask; Respironics small Nasal Comfort fushion mask; Respironics small Full Face Fulllife mask; Respironics Small Child Profile Lite nasal mask. These masks can retail for $185.00+ online. Along with the masks we can provide a Yearly Supply of masks, filters and tubing for. A prescription is required for the mask and yearly supply program.
All prices include USPS First Class shipping:
1 mask for $25.00 Program Fee
2 masks for $45.00 Program Fee
3 masks for $60.00 Program Fee
Donation and prescription must be received prior to shipping.
The ASAA provides no instruction on mask use, mask fit nor follow up care. If you require these services, follow up with your healthcare provider. By submitting this application, you hereby authorize the American Sleep Apnea Association (ASAA) to dispense the prescribed mask or masks that you request below. The mask is offered, new and factory sealed “as is” and without warranty. USPS First Class Shipping is included in the mask package price. If masks are damaged in shipment, please notify us promptly and we will replace. No returns on opened masks. All fees go toward covering our program costs and promoting this service to other patients in need.