STRC CPAP Supplies Request Form
                                                                                       NOTICE
Many insurers including Medicare now require individuals using CPAP and Bilevel PAP equipment to specifically request new supplies rather than being on an automatic resupply program.  


Please use the following Supply Form to Request New Supplies or you may call us direct at:
Phone: 210-617-7012 or 726-444-5226

TYPICAL INSURANCE ALLOWED RESUPPLY SCHEDULES ARE AS FOLLOWS:
  • MASKS (Complete frame and Cushion) - Every 3 Months
  • CUSHIONS Only - Every Month
  • DISPOSABLE FILTER - 2 per Month
  • NON-DISPOSABLE FILTER - Every 6 Months
  • HEATED TUBING / HOSE - Every 3 Months
  • NON-HEATED TUBING / HOSE - Every 3 Months
  • HEADGEAR - Every 6 Months
  • WATER CHAMBER - Every 6 Months
ALL SUPPLIES REQUESTED OUT OF NORMAL RESUPPLY SCHEDULE MAY BE PURCHASED 
Shipping & Handling Charges will apply (these are not covered by insurance)
Pick Up at Clinic - No Extra Charge

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LAST NAME *
FIRST NAME *
MI
DATE OF BIRTH *
MM
/
DD
/
YYYY
BEFORE WE SUPPLY ANY EQUIPMENT WE MUST VERIFY YOUR CURRENT INSURANCE & ELIGIBILITY

Please Update:
INSURANCE  & BILLING INFORMATION
Click here to Update:  INSURANCE UPLINK
(Return Back to this Form after Uploading Current Insurance Card)

Did you update your insurance and billing information?  If not, this will delay you receiving your supplies.
 *
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Required
WHAT CPAP / BILEVEL PAP ARE YOU CURRENTLY USING? *
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Required
What is the name and size of your Mask? *
Example: Medium - AirTouch F20, Dreamwear Full Face Mask - Medium, etc
MASK / INTERFACE (HCPCS PART NUMBER) *
Check all that Apply
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Required
TUBING / HOSE (HCPCS PART NUMBER)
Check all that Apply
 *
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Required
FILTER(S) (HCPCS PART NUMBER)
Check all that Apply
 *
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Required
OTHER SUPPLIES (HCPCS PART NUMBER)
Check all that Apply
 *
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Required
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