Call: 866-499-1588

CPAP Prescription Form Certificate of Medical Necessity

Complete the form below as thoroughly as possible, then click on the "Generate Form" button to create the prescription, you can print the page, sign and date it, and then fax it to Feeling Great!
Patient Information
Insurance Information
Diagnosis
Physician Order
CM / H20
IPAP cm   EPAP cm
IPAP cm   EPAP cm
Mask and Supplies

The following dispensable equipment may be necessary for the proper use of the equipment and is not a part of any PAP machine and needs to be replaced on a regular basis:

  • (A7027) Combo Oral / Nasal Shell (1 per 3 months)
  • (A7028) Oral Cushion for Combo (1 per month)
  • (A7029) Nasal Pillows Combo (2 per month)
  • (A7030) Full Face Mask Shell (1 per 3 months)
  • (A7031) Full Face Seal (1 per month)
  • (A7032) Nasal Seal (2 per month)
  • (A7033) Nasal Pillows (2 per month)
  • (A7034) Nasal Shell (1 per 3 months)
  • (A7035) Headgear (1 per 6 months)
  • (A7036) Chinstrap (1 per 6 months)
  • (A7037) Standard Tubing (1 per 3 months)
  • (A7037) Pressure Line Tubing (1 per 3 months)
  • (A7038) Disposable Filters (2 per month)
  • (A7039) Non-Disposable Filters (1 per 6 months)
  • (A7046) Water Chamber (1 per 6 months)
  • (A4604) Climate Line Tubing (1 per 3 months)
Physician Information

Contact Details

Durham: 919-477-1588
Toll Free: 866-499-1588
E-Mail: support@FeelingGreatSleepCenter.com

Fax Durham: 919-477-1688
Fax Toll Free: 866-499-1288

Sleep Medical Center Locations: Durham, Burlington, Jacksonville, North Carolina
Feeling Great Respiratory Equipment: Oxygen, CPAP / BiPAP, Nebulizers


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