CPAP Mask Assistance Application

Tell Us About The Patient

As a non-profit, 501C3 organization, we often work with research institutions 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.

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

Additional Donation

Payment Due

Payment Options

Please make payment payable to ASAA and not 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 Billing Information

Patient Shipping Information

I hereby release from liability and waive any right to sue the American Sleep Apnea Association (ASAA), their officers, directors, employees, agents, and contractors, from any and all claims, including claims of negligence or physical harm or injury. ASAA 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. The ASAA 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 the ASAA 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 the ASAA makes no warranties or representations, express or implied, to me or any other person with respect to the equipment package. ASAA specifically disclaims all implied warranties including, without limitation, the implied warranties of merchantability, fitness for a particular purpose and non-infringement.