Support

CPAP/BiPAP Device Exchange Request

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IF YOUR DEVICE NEEDS REPAIR OR REPLACEMENT DO NOT USE THIS FORM

Patient Information

First name *

Last name *

Date of birth *

Phone number *

Email address *

Eligibility

Are you a traditional Medicare patient? *

Are you requesting an exchange within 30 days of your therapy start date? *

How many hours are on your current PAP device? *

Shown on your device's usage or info screen.

Current device brand *

Current device model *

Average nightly usage *

How often do you use the device? *

How long have you used your current device? *

Primary reason for exchange *

Troubleshooting

Requested Device

Desired device brand *

Desired device model *

Reason for your selection

Acknowledgements

I understand exchange approval is subject to review and conditions *

I understand that if the hours reported on this form do not match my device's actual hours upon receipt, I will be charged the full exchange fee (shipping, handling, and processing). Please double-check your hours before submitting. *

Your information is sent securely to Medigy and used only to process this request. Questions? Contact us.