NASAL MASK Reorder Form
This reorder form is for NASAL MASK SUPPLIES ONLY.
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  • By checking the box below, I acknowledge the following:

    • Only eligible supplies per my insurance guidelines will be shipped.

    • I am actively using and benefiting from CPAP therapy.

    • If there is a concern with my order Mercyhealth at Home HME will contact me before shipping my order.

    • I have informed Mercyhealth at Home HME of any demographics or insurance changes or other factors that may impact my order (in the comment box above).

    • I am responsible for any copays and charges levied by my insurance as a result of my order.

    “I understand that the information I enter into this form will be transmitted and stored electronically. I further understand that although security safeguards are in place, no system is completely secure. The transmission and storage of this information still involves some privacy and security risk, which I agree to assume.”
  • I ACKNOWLEDGE RECEIPT OF EQUIPMENT AND/OR SUPPLIES ON THIS ORDER. I request that payment of authorized Medicare, Medical Assistance, and/or Medical Insurance Benefits be made either to me or on my behalf for any services furnished me by Mercy Assisted Care, including physicians services, on assigned claims. I hereby guarantee payments to Mercy Assisted Care of any and all charges not covered by this assignment, and waive any and all notices and demands in the event of non-payment there under. I authorize any holder of medical or other information about me to release to the Centers of Medicare and Medicaid Services and its agents any information needed to determine these benefits or benefits for related services.

    For other questions, comments, or concerns, contact MercyHealth at Home HME at 1-800-279-5810