CPAP Assistance Program

CPAP ASSISTANCE PROGRAM

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


INSTRUCTIONS
Complete this form and click submit, attach or email the prescription and make sure your patient pays the program fee. You will receive a confirmation of shipment with a 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 an 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 your patient requires CPAP set up and aftercare service, it is your responsibility to work with your patient to provide these services. We will ship to the office or agency you direct below who will provide these services. Otherwise, your authorization to ship directly to the patient may be indicated below.

To defray program costs and to allow us to continue to help other patients in need, beneficiaries are required to pay a $100 program fee prior to shipping. 

Prescribing Physician Information








ZipPatient Information








Shipping Address











Nasal mask and nasal pillows are only available in size SMALL


Prescribing Physician Acknowledgement

In consideration of my patient participating in the ASAA CPAP Assistance Program, I attest that I am licensed to prescribe this Class 2 Medical Device. In addition, 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 CAP Equipment Package or my patient’s use of the CAP Equipment Package provided; and (2) otherwise related to my patient’s participation in the CPAP Assistance Program. I understand and acknowledge that the ASAA is not responsible for the medical device, its suitability for my patient’s medical condition, or its maintenance, supplies 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 EQUIPMENT 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 Equipment Package does not include a humidifier and does not come with manufacturer warranty or support. I acknowledge that a mask is a bonus and not a guaranteed part of the CAP Package.