ASAA Logo

CPAP MASK APPLICATION


CPAP ASSISTANCE PROGRAM

524 Craig Ave., Tracy, MN 56175 ● Fax 888-293-3650 ● Telephone: 888-293-3650 ● www.sleepapnea.orgmanager@sleepapnea.org

INSTRUCTIONS

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 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. A prescription is required.

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.





Mailing Address




Resmed Quattro FX Full Face       Respironics Amara Gel Full Face    Respironics Full Face Respironics FullLife Full Face Respironics ComfortFusion Nasal Respironics Small Child Profile Lite
Resmed Quattro FX Full Face      
Quattro FX Full Face Mask


Respironics Amara Gel Full Face   
Philips Respironics Amara Gel Full Face Mask


Respironics Full Face
No image Available


Respironics FullLife Full Face
Full Life Face Mask


Respironics ComfortFusion Nasal
Comfort Fusion Nasal Mask


Respironics Small Child Profile Lite
Small Child Profile Lite





Patient Acknowledgement

I hereby release from liability and waive any right to sue the ASAA, their officers, directors, employees, agents and contractors, from any and all claims, including claims of negligence or physical harm or injury (1) related in any way to the mask or my use of the mask provided; and (2) otherwise related to my participation in the CPAP Assistance Program. I understand and acknowledge that the ASAA is not responsible for the mask, its suitability for my medical condition, or its maintenance, or repairs. I ACKNOWLEDGE AND AGREE THAT THE ASAA MAKES NO WARRANTIES OR REPRESENTATIONS, EXPRESS OR IMPLIED, TO ME OR ANY OTHER PERSON WITH RESPECT TO THE MASK PACKAGE. ASAA SPECIFICALLY DISCLAIMS ALL IMPLIED WARRANTIES INCLUDING, WITHOUT LIMITATION, THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NON-INFRINGEMENT. I acknowledge that the CAP Mask Package does not include manufacturer warranty or support.


Need assistance with this form?