Steps to fill out the electronic form and complete your registration
  • Enter the information requested into the appropriate spaces on the form.
  • Select the frequency you would like to receive each item.
  • Review the information you entered for accuracy.
  • Print out the form using the printing feature of your browser. (File > Print)
  • Sign the form to validate your request
  • Mail it to our Supply Replacement Department.

Note
Masks & cushions are not allowed simultaneously. They must be received 30 days apart per Medicare guidelines.
For example, if you receive a mask today, you will not be eligible for a replacement cushion(s) for another 30 days. If any of your supplies ever interfere with one another, we will review them when we contact you.

Supply Replenishment Contact Authorization
"Our automated supply reminder program"

I,  of   hereby authorize Health Management Services, Inc., to contact me at regarding replacement supplies pertaining to my CPAP/BiLevel therapy. I am aware the supply manufacturers recommend replacing supplies at regular intervals as a benefit to patients' health. This precaution helps promote healthier use of equipment and maintains a clean environment. I request the provider contact me regarding the following supplies selected below, at the intervals requested. I understand I may opt out of this agreement or change any item or frequency of contact any time by calling 866-907-0956, email to supplies@hmssleep.com or by written request.

Private Insurance Carriers ONLY: I acknowledge I will be contacted by emails only for my supply reminders.

Mask   ( 1 per 3 month allowed ) Headgear  ( 1 per 6 month allowed )
Items Request 1
Frequency Shipped (month)
3 6 12
Items Request 1
Frequency Shipped (month)
6 12
Nasal Cushion  ( 2 per month allowed ) Full Face Cushion  ( 1 per month allowed )
Items Request 1 x 2
Frequency Shipped (month)
3 6 12
Items Request 1
Frequency Shipped (month)
3 6 12
Nasal Pillow  ( 2 per month allowed ) Tubing  ( 1 per 3 month allowed )
Items Request 1 x 2
Frequency Shipped (month)
3 6 12
Items Request 1
Frequency Shipped (month)
3 6 12
Disposable Filters  ( 2 per month allowed ) Reusable Filters  ( 1 per 6 month allowed )
Items Request 2 x 6
Frequency Shipped (month)
3 6 12
Items Request 1
Frequency Shipped (month)
6 12
Humidifier Chamber  ( 1 per 6 month allowed ) Chin Strap  ( 1 per 6 month allowed )
Items Request 1
Frequency Shipped (month)
6 12
Items Request 1
Frequency Shipped (month)
6 12

By signing this agreement I grant HMS permission to contact me to confirm my request for these replacement supplies, they will not be shipped automatically. HMS will bill my health insurance on my behalf for supplies shipped. I also understand I am liable for any co-payments and/or deductibles set forth by my health insurance.

Signature__________________________________ Date_________________________________