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Full Name
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Current Address, City, State, Zip code
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Phone Number (best at which to be reached during normal business hours)
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Email address
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In case we need to obtain a new prescription for this order, what doctor are you currently seeing?
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Primary & Secondary Insurances
No insurance changes from last order
Change in insurance
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New Insurance Company, Group #, ID # and insurance phone #:
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Check the supplies that you would like to order.
Mask
Headgear
Filters
6' Tubing
Cushion
Chin Strap
Chamber
Other
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Describe any other supplies not listed that you want to order.
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For insurance coverage purposes, how many hours a night do you use your CPAP or Bi-Level?
4-5 hours a night
5-6 hours a night
6 or more hours a night
Other: Less than 4 hours a night
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On average, how many nights a week do you use your CPAP or Bi-Level?
5 nights a week
6 nights a week
7 nights a week
Other: Less than 5 nights a week
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How would you like to receive your supply order?
Pick up at the Babcock office location
Have shipped to your current address
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How would you like to pay for your portion of the cost of the supplies?
At the Babcok office by cash, credit card or check
With on-line payment from check or credit card
Over the phone with a service representative
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Once you send in your order request, one of our customer service representatives will email you with your financial responsibility amount for the supplies. This will be determined after we verify the portion your insurance company will cover. This process may take up to 48 hours. Thank you for your order request!
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