CPAP Supplies Reorder Form

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*
Insurance Card Back*
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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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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