CPAP/BiPAP Device Exchange Request

CPAP/BiPAP Exchange Request Form

Contact Information

IF YOUR DEVICE NEEDS REPAIR OR REPLACEMENT

DO NOT USE THIS FORM

First name

Last name

Date of birth

Month

Day

Year

Phone number

Eligibility

How long have you been using your current CPAP device?

Less than 14 days

14–30 days

30–90 days

90+ days

Are you requesting an exchange within 30 days of your therapy start date?

Yes

Section 2: Current Device Experience

How often are you currently using your device?

Not using

1–3 nights per week

4–6 nights per week

Every night

Average nightly usage (hours)

Less than 2 hours

2–4 hours

4–6 hours

6+ hours

Troubleshooting

Please confirm what you have already tried

Adjusted humidity settings

Requested pressure setting adjustments (if applicable)

Reviewed device instructions

Contacted support for assistance

Used device consistently for at least 2 weeks

Requested Device

Reason for selecting this device (optional)

Acknowledgements

I confirm I have used my current device for at least 30 days

I understand device exchanges are subject to approval

I understand there is a $150 exchange fee (excluding Medicare patients)

I understand this exchange does not reset any compliance requirements

Payment

CPAP Exchange Fee

$150