CPAP Machine Assistance Application
Tell Us About The Patient
First Name
Last Name
Email
Phone
Patient Mailing Address
Street
City
State Code
Zip Code
Is the billing address the same as the mailing address?
Yes
No
Patient Billing Address
Street
City
State Code
Zip Code
Why is the patient interested in this program?
Please explain:
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
Birthdate (MM/DD/YYYY)
Ethnicity
Household Income
Machine Equipment Package
Machine Type
Mask Style
Mask Size
Additional Comments
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?
Where did you hear about the CAP Program?
Other Detail
Would you like to subscribe to our newsletter?