CPAP Machine Assistance Application

Instructions

To apply for a PAP device, please carefully follow these steps:

  1. Complete the Application:
    • Fill out all required fields on the form.
  2. Provide Supporting Documents:
    • Upload a copy of your PAP prescription if it is not already on file. Make sure the prescription includes the prescribed pressure settings. If you are unable to upload your prescription, use one of the following methods:
      1. Fax it to 888-293-3650
      2. Email it to manager@sleephealth.org
      3. Mail to: ASAA, PO Box 1072, Tracy, MN 56175.
  3. Submit Your Application:
    • After completing all required fields, click Submit to finalize your application.
    • You will be prompted to electronically sign the form, which includes a verification step sent to your email. This verification must be completed to process your application.

Important Notes:

  • Inventory and Waitlist:
    • Due to limited inventory, there is currently a waiting list for Auto CPAP devices. Submitting your application and prescription ensures your eligibility is verified and places you on the waitlist for the next available machine. 
    • CPAP and Bilevel devices are readily available and do not have a waiting list.
  • Program Fee and Payment Process:
    • The program fee is $200.00 and must be paid before shipping.
    • When a device becomes available, we will notify you via email with instructions for making your payment.
    • You must respond within 48 hours of notification to secure your machine. Failure to pay or make payment arrangements within this timeframe may result in losing your spot on the waitlist.
  • Shipping Information:
    • Shipping within the continental United States is included in the program fee and will be sent via USPS.
    • Residents of Hawaii or Alaska will be charged an additional $20.00 for USPS shipping.
  • Equipment Package Details:
    • Each package includes:
      • A gently used PAP machine, 
      • General non-heated universal tubing, 
      • Filter, 
      • Water reservoir, 
      • Carrying case.
      • A Full-face mask (including frame, cushion, and headgear) is provided. If you prefer a different mask style, please specify your preference and size on the application form. While we will make every effort to accommodate your request, but availability cannot be guaranteed.


For additional assistance or questions, contact us at manager@sleephealth.org.

Tell Us About The Patient




Patient Mailing Address





Patient Billing Address






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.

Month Day Year
Birthdate


Machine Equipment Package






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





Patient Acknowledgment
  1. Equipment Condition:
    • The equipment package is offered "as is" with no manufacturer warranty or technical support.
    • The machine may be gently used.
  2. ASAA’s Role:
    • The American Sleep Apnea Association (ASAA) is not a Durable Medical Equipment (DME) Supplier or DME Provider. 
    • ASAA provides a 30-day warranty in case of damage during shipment or mechanical failure and will replace the machine at no cost under these circumstances.
  3. Responsibility & Liability:
    • ASAA is not responsible for the medical device itself, its suitability for my medical condition, or any issues related to its set-up, maintenance, supplies, or repairs.
    • I release ASAA, its officers, directors, employees, agents, and contractors from any and all claims, including claims of negligence, physical harm, or injury related to the equipment or its use.
  4. No Refund Policy:
    • I understand and agree that once the equipment package has been shipped, the program fee is non-refundable under any circumstances.
  5. Shipping Disclaimer:
    • ASAA is not responsible for delays in shipping due to circumstances beyond its control, such as shipping carrier delays or natural disasters.
  6. Mask Selection and Compatibility:
    • If I request a specific mask style or size, I understand that ASAA will attempt to accommodate my preference but does not guarantee availability.
    • I am responsible for ensuring that the selected mask and equipment are compatible with my prescribed therapy and personal needs.
  7. Health Disclaimer:
    • I understand that the PAP equipment provided by ASAA is not customized for my specific medical condition, and I should consult with my healthcare provider to confirm its suitability and proper use.
  8. Contact Information for Issues:
    • If the device or other components are damaged during shipping or if I encounter any other issues, I will promptly contact ASAA at manager@sleephealth.org for assistance.
  9. No Warranties or Representations:
    • ASAA makes no warranties or representations, express or implied, regarding the equipment package.
    • All implied warranties, including but not limited to the implied warranties of merchantability, fitness for a particular purpose, and non-infringement, are expressly disclaimed.