CPAP Mask Assistance Application

Instructions

To apply for the CPAP Mask Assistance Program, please follow these steps carefully:

  1. Complete the Application:
  • Fill out all required fields in the online application form. 
  • If you have a specific request regarding your mask or tubing, please note this on the application in the additional comment section or contact WSCN 
  1. Phone: 888-293-3650 
  2. Email: manager@sleephealth.org
  • WSCN cannot guarantee special requests, but we will do our best to accommodate your preference. 
  • Provide Your Prescription:
    • Upload a copy of your CPAP prescription with the prescribed pressure settings, unless we already have a prescription on file. 
    • If unable to upload it, you can send it using one of the following methods:
    1. Fax: 888-293-3650
    2. Email: manager@sleephealth.org
    3. Mail: WSCN, PO Box 1072, Tracy, MN 56175
  • Pay the Program Fee:
    • The program fee helps cover program costs, including shipping via USPS First Class (an additional $5.00 applies for Hawaii or Alaska). Payments can be made using one of the following methods:
    1. Online: An online payment option will follow the application form upon submission.
    2. Certified Funds: Money order or certified check (no personal checks), payable to WSCN and mailed to:
      WSCN, PO Box 1072, Tracy, MN 56175
    3. Phone: Call 888-293-3650 to process payment with a debit/credit card.
  • Submit Your Application:

    • After completing all required fields, click Submit to finalize your application.

    1. Confirmation and Shipment:
    • Shipments will not be processed until your application is fully completed, the prescription is received, and the program fee is paid in full.
    • Standard USPS First Class shipping is included for shipments within the continental United States.


    For additional assistance, please contact us at manager@sleephealth.org or call 888-293-3650.

     

    Tell Us About The Patient






    Demographics

    As a non-profit, 501(c)(3) organization, we often work with research institutions and other healthcare organizations. Please complete the questions below. Your responses are used for reporting purposes only and will not affect your program status. We may share general program statistics, but we will not share your personal information.





    CPAP Mask Information
    Special requests may be noted of the brand, model and/or style preferred, but are not guaranteed.








    Additional Donation

    Enter numbers only
    Payment Due
    Patient Acknowledgment

    I acknowledge and agree to the following:

    1. Release of Liability:
    • I hereby release from liability and waive any right to sue the Wellness, Sleep & Circadian Network (WSCN), their officers, directors, employees, agents, and contractors, from any and all claims, including claims of negligence, physical harm, or injury.
  • Insurance and Program Fee:
    • WSCN’s CPAP Program is not covered by medical insurance providers, nor will the organization bill any insurance company.
    • The program fee is a low-cost alternative that ensures this program can remain sustainable for those without medical insurance or those experiencing financial hardships.
  • Healthcare Provider Responsibilities:
    • The WSCN does not provide instructions on mask use, mask fit, or follow-up care.
    • I understand that it is my responsibility to consult with my healthcare provider for these services and for any questions regarding the equipment's suitability for my medical needs.
  • Mask Selection and Replacement:
    • By submitting this application, I authorize WSCN to dispense the prescribed mask(s) I have requested.
    • Masks are provided new, factory sealed, and offered “as is” without warranty.
    • If my specific mask request is unavailable, I consent to the shipment of a full-face mask as an alternative.
    • If masks are damaged during shipment, I will promptly notify WSCN to arrange for a replacement. No returns or replacements are permitted for opened masks.
  • No Warranties or Representations:
    • I acknowledge and agree that WSCN makes no warranties or representations, express or implied, regarding the equipment package.
    • WSCN specifically disclaims all implied warranties, including, without limitation, the implied warranties of merchantability, fitness for a particular purpose, and non-infringement.
  • No Refund Policy:
    • I understand and agree that once the equipment package has been shipped, the program fee is non-refundable under any circumstances.
  • Acknowledgment of Agreement:
    • By submitting this application, I confirm I have read and agree to the terms outlined above. I also agree to move forward with the shipment of a full-face mask if my specific request cannot be fulfilled.


    Payment Options

    Please make payment payable to WSCN and note your application # on the payment. Payments should be mailed to PO Box 1072, Tracy, MN 56175
    Please call 888-293-3650 to make your payment over the phone with one of our staff
    Credit Card Details






    Patient Shipping Information




    Due to limited inventory, we currently have a waitlist for CPAP equipment. We know this may be difficult news, and we truly appreciate your patience as we work hard to get equipment to everyone in need.


    Patient Billing Information






    I hereby release from liability and waive any right to sue the Wellness, Sleep & Circadian Network, Inc. (WSCN), their officers, directors, employees, agents, and contractors, from any and all claims, including claims of negligence or physical harm or injury. WSCN CPAP Assistance Program is not covered by medical insurance providers, nor will the organization bill any insurance company. The low program fee for your PAP masks assures that the program can be sustained for those without medical insurance coverage or those experiencing financial hardships. WSCN provides no instruction on mask use, mask fit nor follow-up care. If you require these services, please follow up with your healthcare provider. By submitting this application, you hereby authorize WSCN to dispense the prescribed mask or masks that you requested. The mask is offered new and factory sealed “as is” and without warranty. If masks are damaged in shipment, please notify us promptly and we will replace them. No returns are accepted for opened masks.  I acknowledge and agree that WSCN makes no warranties or representations, express or implied, to me or any other person with respect to the equipment package. WSCN specifically disclaims all implied warranties including, without limitation, the implied warranties of merchantability, fitness for a particular purpose and non-infringement.