CPAP Refills


Please fill out and submit the form below to refill your CPAP online. This form is for refills ONLY and any NEW CPAP request MUST be presented at the pharmacy for filling. Thank you!

* Denotes required fields

  • *When and where would you like to pick up your order?:

  • Please allow 24 hours to process your order, or 2 days if order is placed on Saturday.

  • If your insurance has changed since the last time you received supplies, please contact a home medical representative from your respective location.

  • For those with Medicare coverage:
    Medicare determines the frequency that you can receive certain items. Check with your medicare provider for allowed time periods.
  • Customers with commercial insurance plans:
    We can bill most insurance carriers and they typically will cover these items every 6 months. Your home medical representative will determine what you are eligible for under your plan.
  • All insurance plans: You will be responsible for any deductible or co-pay before we can bill your insurance.

    Please be aware that you will be responsible for any co-payment or deductible amount that your insurance requires. If your insurance requires a pre-authorization or if you need a new prescription, we will request it and then your order will be processed.

  • Please select the supplies that you would like to have refilled:

  • Check this box if you would like to have your supplies mailed.
    • Nasal Cushion
  • Additional Information

  • Other Concerns

  • Note or Special Instructions: