Dear Valued Patient:

You have the opportunity to sign up for Med-South’s PAP Resupply Program. Once enrolled, Med-South will start mailing out your sleep supplies on a quarterly or semi-annual basis.

Please select which option you prefer:

Positive Airway Pressure (PAP) sleep supplies to be shipped to patient every 3 months.

• 1 Mask or Pillow Interface

• 1 Tubing

• 6 Disposable Filters

• Every 6 months, 1 Headgear and 1 Humidifier Chamber

• If applicable every 6 months, 1 Chinstrap and 1 Non-Disposable Filter for the PAP unit

Positive Airway Pressure (PAP) sleep supplies to be shipped to patient every 6 months.

• 1 -  Mask or Pillow Interface

• 1 - each Headgear, Tubing and Humidifier Chamber

• 6 - Disposable Filters

• If applicable, 1 Chinstrap and 1 Non-Disposable Filter for the PAP unit
  
  

Please select which cushion/pillow replacement option you prefer:

Cushions/Pillows, Option 1 (changed more frequently): Please send Nasal (5 each) or Full Face (2 each) Cushions or Nasal Pillows (5 pairs) with each Opt-In supply shipment when allowed by my insurance provider.

Cushions/Pillows, Option 2 (changed less frequently): Please send Nasal (2 each) or Full Face (2 each) Cushions or Nasal Pillows (2 pairs) with each Opt-In supply shipment when allowed by my insurance provider.

*Please note that the supplies actually included in your replacement package will be governed by your insurance plan and may be different than the selections indicated above. Also be aware that replacement schedules are subject to change based upon prescriber orders, patient medical condition(s) and the discretion of your insurance company.

Patient Information

Patient Name   

Date of Birth            Phone  

Email Address   

Insurance Name           Insurance ID  

Current machine  (Mfg/Model)

Sleep Physician Name   

Mask (Style/Size)    

If you would like to participate in the Opt-In program, please fill in your name and sign below.

By my signature below, I authorize Med-South Inc.  to send me PAP supply shipments at the interval indicated above. I understand that I am responsible for any portion of the cost not covered by my insurance plan, including applicable coinsurance and deductibles, and that I must communicate any changes to my insurance coverage to Med-South Inc. as soon as possible. I further understand that this Opt-In program is not available to patients with certain payors, such as Medicare, Medicaid, managed Medicaid, or TRICARE.

Print name 

Relationship to patient   

Patients who wish to order supplies more frequently, order different supplies, or cancel their Opt-In enrollment should call Med-South’s Sleep Management Center at (205) 221-8318.

Please sign and click Agree below to send this form to Med-South Inc. for processing. 

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Change fonts

• Draw Signature
  
• Type In Signature
  

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

Insert Signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signature Certificate

Document name: PAP Resupply Program Opt-In Enrollment

Unique Document ID: 05fdbcba031843b8320cb370aab473cb4edf94c7

Build. Track. Sign Contracts.

Timestamp	Audit
November 11, 2020 2:29 pm CDT	PAP Resupply Program Opt-In Enrollment Uploaded by Ran Reding - ran@danmarkcom.com IP 12.233.60.59

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://medsouthinc.org/

Audit Trail Serial# 48d8af67cf79d87117bae5710ff3070f