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Pay Bill Patient Portal Supplies Portal Billing Portal

CPAP Supply Order Form

Whitney Sleep Center offers a selection of CPAP supplies. Please use the form below to place an order.

*This form is for current patients. If you’re new to our clinic, please call us at 763-519-0634.

"*" indicates required fields

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Patient Information

Full Name*

As on insurance card.

First Last

Date of Birth*

MM slash DD slash YYYY

Phone Number*

Email Address*

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Ordering Method

Order Method*

Bill to Insurance

Self-Pay (Pay Out of Pocket)

Best Phone Number for Payment*

Payment must be made prior to shipping. We will contact you at this number to process your payment.

Primary Insurance Carrier*

Insurance ID Number*

Group Number (if applicable)

Order Details

Please select the supplies you need (check all that apply)

Mask Frame

Mask Headgear

Nasal Mask Cushion/Pillow

Full Face Mask Cushion/Pillow

Heated Tubing

Standard Tubing

Disposable Filters

Reusable Filters

Water Chamber

Chin Strap

Other

Other Supplies*

Nasal Mask Cushion/Pillow Quantity*

Up to 6 for nasal per order.

Please enter a number from 1 to 6.

Full Face Mask Cushion/Pillow Quantity*

Up to 3 for full face per order.

Please enter a number from 1 to 3.

Disposable Filters Quantity*

Please enter a number greater than or equal to 1.

Reusable Filters Quantity*

Please enter a number greater than or equal to 1.

Insurance & Eligibility Information

Insurance & Eligibility Information*

Insurance orders are subject to your coverage and eligibility at the time of service.

Typical replacement timeframes for commercial insurance (may vary by plan):
- Mask Frame: every 3 months
- Nasal cushion Cushion/Pillow: up to 6 every 3 months
- Full Face cushion: up to 3 every 3 months
- Headgear: every 6 months
- Heated Tubing/Standard tubing: every 3 months
- Disposable Filters: up to 6 every 3 months
- Reusable Filters: 1 every 6 months(Respironics and React Health Machines Only)
- Water Chamber: every 6 months

If your plan does not cover an item or you are not eligible, you will be contacted prior to shipping.

I acknowledge the Insurance & Eligibility Information*

Agreement

Agreement*

Select at least 3 choices.

Select All

I understand that self-pay orders must be paid in full prior to shipping.

I understand that insurance orders will be billed according to my coverage and eligibility at the time of service.

I authorize Whitney Sleep Center to ship the supplies I have selected.

Signature*

Date*

MM slash DD slash YYYY

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masonw@whitneysleepcenter.com

Plymouth

2700 Campus Drive, Suite 100
Plymouth, MN 55441

(763) 519-0634

Burnsville

2412 East 117th Street
Burnsville, MN 55337

(952) 431-5011

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