Respiratory Therapy - Center for Connected Care PAP Supply Re-order Form

Patient Information

If you are requesting supplies, please indicate medical necessity by selecting YES to the questions below.

Items marked with * are required.

Is the mask cracked or experiencing air leakage?
Do the filters appear clogged, have dust, dirt or pollen build-up?
Does the tubing have air leakage or cloudy in appearance?
Is the headgear worn, stretched or not adhering?
Is the chinstrap worn, stretched or not adhering?
Is the water chamber / humidifier leaking, has dirt or residue build-up?
Is the cushion / nasal pillow cracked, worn or experiencing air leakage?

Cleveland Clinic will send a 90 day supply for requested items. Cleveland Clinic will only send supplies which you are eligible and qualify for based on your insurance coverage. We will NOT automatically reorder supplies, without your request.

Version: 2023-10-27 1003

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