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CPAP Prescription Order Form

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CPAP Prescription Order Form

Submit your order using this online form. 

Questions? Use the live chat window (below, lower right) or call 402-408-1990 during business hours, or contact us.

Patient Information

Name(Required)
Address(Required)
Date of Birth(Required)
Sex(Required)

Kohll's Rx Location

Which Kohll's Rx Location would the customer prefer to use?(Required)

Order Information

Each order will contain:
  • CPAP machine
  • 1 heated tubing every 3 months
  • 1 mask every 3 months
  • 6 filters every 3 months
  • 1 cushion each month
  • 1 humidity chamber every 6 months
This field is hidden when viewing the form
Order Contents
Diagnosis(Required)

MM slash DD slash YYYY
Clear Signature
Date: 03/14/2025

Prescriber Information

Address(Required)
NPI must match the person whose signature appears above.
Please attach chart notes. In order for insurance to approve your patient's order, every detail filled out above must be documented in the chart notes. If you know an item is missing, please make an addendum before uploading. If you are unable to upload, please fax the chart notes to: 402-895-3155.

Claims will not be submitted to insurance without chart notes.

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Max. file size: 100 MB.
    Drop files here or
    Max. file size: 100 MB.
      Acknowledgement(Required)
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