Resupply

Patient's Name (required)

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Date of Birth (mm/dd/yy) (required)

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Patient's Email (required)

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Select whether address is the same as previous order or new address (required) Same Address as Previous Order New Address

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Provide your current address:

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Select whether insurance info is the same as previous order or new insurance info (required) Same Insurance as Previous Order New Insurance

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Provide your new Insurance Info:

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Approval to charge expenses not covered by insurance to the credit card that we have on file (required) Yes No

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NOTE:

This order will be processed through the insurance company on file. If your insurance information has changed please call us to update our records.
The Resupply order will be filled based on the information of your previous orders on file.
We may need an updated compliance report for insurance authorization before we ship your order.
Any outstanding balances, deductibles, co-pays or out of pocket payments will be due before your items are shipped.

MASK with Headgear and Cushion CUSHION NASAL PILLOWS ULTRA FINE FILTER REUSABLE FILTER HUMIDIFIER CHAMBER CHIN STRAP

Comments - Please be sure to add any additional information to help process your order.

Would you like pricing and availability on any other equipment/supply?

Landauer-Medstar, an AdaptHealth company, is not affiliated any way with Landauer, Inc.