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Kohlls Rx

Locally owned and operated since 1948.

402-408-1990 / 866-500-7800

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You are here: Home / Home Medical Equipment / Respiratory / CPAP Supplies Reorder Form

CPAP Supplies Reorder Form

"*" indicates required fields

Name*

First Last

Date of Birth*

Email*

Phone*

Insurance Information

How would you like to submit your insurance information?*

Upload images of my insurance card

Enter my insurance card information

Insurance Card Images

Insurance Card Front*

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.

Insurance Card Back*

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.

Insurance Card Information

Health Insurance Company*

This is often in the corner of your insurance card.

Health Insurance ID #*

This can also be called Policy # or Member ID.

Health Insurance Group #

Doctor & Order Information

Doctor's name that manages your sleep apnea*

Doctor's Office Location

Doctor's Phone Number

What size and model of mask do you use?

This is often on the front of your mask.

Are your supplies starting to show signs of normal wear and tear?*

YES

NO

What kind of mask do you want to order?

Full face mask (1 per 3 months) + headgear + Full face cushions (2 per 3 months)

Nasal mask (1 per 3 months) + headgear + Nasal cushion (5 per 3 months)

What kind of tubing do you want to order? (1 per 3 months)

Heated Tubing for ResMed Device

Heated Tubing for Philips Device

Universal 10 ft Tubing

Universal Slim Tubing

Universal 6 ft Tubing

What other supplies do you want to order?

Disposable filter (6 per 3 months)

Reusable filter (1 per 6 months)

Chinstrap (1 per 6 months)

Water chamber (1 per 6 months)

How do you want to pay for your copay if you have one?

Charge my credit card that is on file already

Please call me to get my credit card information to keep on file

I'll stop by your location and pay in person

Is it ok to text you updates and questions as we go?

YES

NO

Notes & Comments

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Email

This field is for validation purposes and should be left unchanged.

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Kohll's has been serving patients in Omaha, Lincoln and western Iowa since 1948. We provide high-quality service to better your health.

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Locations:

Do you have COVID-19 questions? Use our Contact Form to receive the quickest response.

Call 402-973-1947 for our COVID-19 team.

2915 Leavenworth St / 402-342-6548
12741 Q St / 402-895-3102
5002 Dodge St / 402-553-8901
808 N 27th St (Lincoln) / 402-476-3342
403 Main St (Malvern) / 712-624-9050

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