www.LowestCPAPprice.com

Express CPAP Supply
1471 Pomona Road Unit H
Corona, CA 92882
951-663-2120
951-808-0616 - Fax
sales@LowestCPAPprice.com - E-Mail

Physician Authorization Form

Dear Physician:

One of your patients is requesting new or replacement CPAP products to treat their sleep apnea.

Please authorize Express CPAP Supply to dispense these items by completing the authorization form below.

________________________________________________ __________________
Patient Name:                                                                                                       Patient Date of Birth:

__________________________________________________________________
Patient Address:                                                                                                        Patient Phone #

Please check the following that apply:

____ CPAP Machine and Accessories. Pressure Setting:_______

____ Automatic CPAP Machine/Accessories Pressure Range:______

____ BiPAP Machine/Accessories Pressures: Inhale____ Exhale____

____ CPAP Mask System

____ CPAP Accessories, including humidification ___________________

____ Oxygen Concentrator  Liters _________

____________________________________________ _____________________
Physician's Signature License/DEA #                                                           Date

Physician's Stamp (Name/Address/Phone) - Required
____________________________________________________

X                                                                                   X

X                                                                                   X

X                                                                                   X

X                                                                                   X

____________________________________________________