North Arlington PAP Supplies Request

If you have been prescribed PAP equipment by a Texas Pulmonary & Critical Care Consultants physician in our N. Arlington office, you may request replacement PAP supplies using the form below. Please note that we cannot bill Medicare, Medicaid, or TriCare insurance for these supplies.

You will be contacted at the phone number/email below so we may get details needed to complete your request. You'll then be advised when your requested supplies are being mailed or are ready to pick up.

If you have questions about this form or about your PAP Supplies, please call the office at (817) 461-8772, or email narlpapsupplies@tpsctr.com.


*Required Today's date
Account Number (if known): *Date of Birth (MM/DD/YYYY):
*First Name: *Last Name:
*Address:
*City: *Zip:
*Phone:
Email:
Check here if your insurance has changed since your last visit to our office.
   

By submitting this form, you are requesting that we issue replacement PAP supplies to you. If you do not presently get your PAP supplies from us, please enter the name of your current DME company so we may contact them to obtain information about your supplies:


Most insurance companies allow the following replacement schedule for PAP supplies:
Monthly (31 days) Paper filters
Soft cushions
Nasal pillows
Every 3 months (93 days) Full-face mask
Nasal mask or nasal device
Six-foot tubing
Every 6 months (186 days) Headgear
Chin strap
Humidifier canister
Foam filters

Select

Item (hover your mouse cursor over the to see a sample item)

Humidifier Chamber (replacement)
Mask System (Full Face) with Headgear
Mask System (Nasal) with Headgear
Mask System (Nasal Pillows) with Headgear
Mask Interface - Full Face Mask Cushion
Mask Interface - Nasal Mask Cushion
Replacement Nasal Pillows
Hybrid Oral/Nasal Combo Mask
Hybrid Oral Cushion
Hybrid Nasal Pillows Replacement
Headgear
Chin Strap
Tubing
Filter, Disposable (white paper or foam)
Filter, Non-Disposable (black foam)
Oral Interface
Other:

Enter any notes you might have for our staff:

Choose how you would like to get your supplies:

Ship my supplies to the address above. (Shipping charges apply.)
I will pick up my supplies from the office at 907-B Medical Centre Dr., Arlington, TX.

Note: This is a non-secure communication. You must indicate your acceptance of the use of this form by checking the box below.

*I hereby acknowledge that this form is unencrypted and not a secure means of electronic communication with my healthcare provider or facility. I agree to allow my healthcare provider or facility staff to reply to the email address indicated on this form, and to forward or share the information contained in this form, including any Personal Health Information (PHI), with other health professionals or associated staff using non-secure electronic communication methods such as email.