Extended Warranty Claim Form

Submit this form if you have purchased an extended warranty for your CPAP or BiPAP device and are experiencing an issue. Our team will review your request and confirm eligibility and next steps.

Section 1 — Patient Information

First

Last name

Date of birth

Month

Day

Year

Phone number

Email address

Section 2 — Device Information

Device type

Brand

Model

Serial number

Date device was received

Section 3 — Warranty Information

Which extended warranty did you purchase?

Section 4 — Issue Details

What issue are you experiencing?

Describe the issue

Section 5 — Troubleshooting

Section 6 — Device Condition

Has the device been exposed to water internally?

Yes

Not Sure

Has the device been dropped or physically damaged?

Yes

Section 7 — Upload

Upload photos

Upload your file

Choose a file or drag and drop one here.

Please upload photos of: device, serial number label, any visible damage

Section 8 — Acknowledgment

I understand and confirm the following:

• This request is for an extended warranty claim and is subject to review and approval • The device has not been intentionally damaged • The device has not been exposed to internal water damage • I am not submitting false or misleading information • Additional information may be required to process this claim

I understand that Medigy will make every attempt to replace the defective unit with the same unit. If not available, a refurbished unit or a newer model may be utilized.

Section 9 — Final Confirmation

I confirm that the information provided is accurate and understand that warranty eligibility will be determined upon review.