Patient Authorization Form

Prescription Required

This device requires a prescription to purchase which you will be able to upload after checking out.

If you do not have your prescription our Medical Records team will work with you and your doctor to obtain a valid prescription.  If you have any questions or would like assistance, please call 800-311-5840.

A valid prescription:

✔ Must include one of the following terms:
For CPAP: Continuous Positive Airway Pressure, or CPAP
For APAP: AutoPAP, APAP, Auto Adjusting or Self Adjusting CPAP, Auto Set, Auto CPAP, Continuous Positive Airway Pressure or CPAP, Auto-titrating

✔ Must include settings:
For CPAP: Your specific single pressure setting: ___ CM/H20
For APAP: Your pressure range from ___ to ___ CM/H20

✔ Your physician’s signature

✔ Your physician’s contact information (including fax)

✔ The patient’s full name

✔ Valid date

For more information on our Prescription Policy, please click HERE.