CAP Natural Disaster Assistance Program

By submitting this application, you hereby authorize the American Sleep Apnea Association (ASAA) to

dispense the prescribed equipment package that you request below. The equipment package consists of one of the following:

Machine, which includes a continuous positive air pressure machine, tubing, filter, carrying case, and full face mask. You may request a different style mask, but your request may not be guaranteed. Please select a mask style and size on the form, and we will include it if we have your choice in our inventory.

Year Supply, which includes four masks, two tubes, and four filters.

Tell Us About The Patient

First Name

Last Name

Phone

Mailing/Shipping Street

City

State Code

Zip Code

Where did you hear about the CAP Program?

Would you like to subscribe to our newsletter?

As a non-profit, 501C3 organization, we often work with research institutes and other healthcare programs. Please complete the questions below. These questions are optional and only used for reporting purposes. Responses will not affect your program status.

Gender

	Month	Day	Year
Birthdate

Ethnicity

Household Income

Natural Disaster Information

Please provide what natural disaster has affected your current situation and why you are looking for a used PAP Device from our CPAP Assistance Program.

Equipment Package

Which package are you interested in?

MachineYear Supply

Machine Type

Which CPAP machine are you currently using?

Mask Style

Mask Size

How will you send your prescription?

Upload your file

As a participant in the programs available through the American Sleep Apnea Association (ASAA), please provide the following Information:

How many nights a week are you using CPAP now?

How many hours per night are you using CPAP now?

Contact Information