Sleep Therapy 5 Year Replacement Machine Request

Start the process of replacing your CPAP, APAP, or BiPAP machine after five years of use.

Please fill out and submit the form below to begin the process of replacing your sleep therapy equipment.

Along with this form, we will require the following documentation to qualify you for a new machine. Once we receive your request we will begin working with you and your clinician on obtaining it:

Face to face office visit within the last 6 months discussing use and benefit of the equipment
New prescription that includes the appropriate pressure and related supplies
Recent compliance download

After you submit, a confirmation page will appear. Need help? Call 1-866-229-5418.

1Patient information

First name *

Middle name *

Last name *

Date of birth *

2Preferred method of contact *

Text

Phone

3Doctor information

Name of your sleep or pulmonary doctor *

Date of last appointment

4Delivery preference *

Once we are able to dispense your new machine, how would you prefer to receive it?

Mailed to you, no appointment (free shipping)

Virtual appointment with staff

Pick up in office

5Security check

Need help? Call 1-866-229-5418 and we can submit this with you.