CPAP ASSISTANCE PROGRAM
● 524 Craig Ave., Tracy, MN 56175 ● Fax 888-293-3650 ● Telephone: 888-293-3650 ● ● www.sleepapnea.org ● email@example.com ●
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.