US Med | CPAP Reorder

CPAP Re-Order Form

You may receive 2 nasal cushions/pillows or 1 full face cushion per month in addition to the new mask every 3 months.

Cushion Mask Selection

I agree to the following by submitting the form below:

Send me a new mask and tubing upon receipt of this form, or after 90 days since my last mask, whichever is later.
I use my mask at least 4 hours every 24 hour period.
I will continue my CPAP therapy.
I have used CPAP device for the preceding 2 months.
I acknowledge receiving my last shipment.

Name: First | Last *

Phone *

* Please complete the following if any of your information has changed:

Street Address

City, State Zip

Primary Insurance Company:

Primary Insurance Policy # or Medicare #:

Primary Insurance Company Phone #:

(*leave blank for Medicare)

Secondary Insurance Company:

Secondary Insurance Policy #:

Secondary Insurance Company Phone #:

United States Medical Supply • 8260 NW 27th Street, #401 • Miami, FL 33122

call us 1-800-7-USMED-1