ࡱ>  HbjbjVV 4J<< z"z"////////8 0\e0d/9.01(222C33dO44P9R9R9R9R9R9R9$#;=v99/6C3C366v9//22498886F/2/2P986P98882 Q#B/d68<99098s>d6s>8s>/84L4685,15444v9v9X7044496666s>444444444z" .: PATIENT:  FORMTEXT       MEDICAL REC #  FORMTEXT       DME SUPPLY REPLACEMENT AUTHORIZATION Return this form by fax to 817.860.8772 or email to Texas Pulmonary Sleep Center would like to remind you that the effectiveness of your PAP treatment requires a good fit of your mask/headgear (interface) to minimize leaks in the delivery of pressure. Over nightly usage comes wear and tear that takes a toll on the elasticity and composition of the mask structure, which can result in leaks and thus can cause a loss of airway pressure. To ensure that your mask/headgear is fitting optimally, it is recommended that your supplies be replaced regularly. For your convenience, your supply replacements can be automatically provided to you either by automatic shipping (postage rates will be applied) or you can pick-up with call ahead confirmation without scheduling an appointment. Should you have other needs, such as mask consultations, equipment service or compliance downloads, you will still be required to schedule those services with our respiratory specialist during regular office hours. To take advantage of these supply convenience services, please select your preferences by indicating below: Clinical Recommendation of Replacement Supplies (please check each supply to authorize replacement at recommended intervals) ItemSupply NameItem DescriptionRecommended Replacement FORMCHECKBOX PAP Tubing6 tubing used with PAP device1 per 3 months FORMCHECKBOX Mask (Full-Face) Complete appliance used with PAP device1 per 3 months FORMCHECKBOX Mask (Nasal)Complete appliance used with PAP device 1 per 3 months FORMCHECKBOX Full Interface Replacement full-face mask interface only1 per month FORMCHECKBOX Nasal InterfaceNasal mask or nasal pillow interface only2 per month FORMCHECKBOX HeadgearUsed with mask appliance with PAP device1 per 6 months FORMCHECKBOX H20 chamberUsed with PAP device heated humidifier1 per 6 months FORMCHECKBOX Filter (N/Disp) Non-disposable filter used with PAP 1 per 6 months FORMCHECKBOX Filters (Disp)Disposable filters used with PAP2 per month I,  REF ptname   have received the information regarding the use, care, and replacement of my supplies. I understand that I may be responsible for full or partial payment of CPAP/BIPAP masks and/or supplies if my insurance provider does not cover this expense due to deductibles that apply or changes to my insurance coverage. I also understand that I am required to provide written notice to TPSC to stop the shipment of supplies according to the terms of this agreement.  FORMCHECKBOX  I am requesting to have supplies shipped to me according to my selection above. Please make prior financial arrangements for shipping (charged to credit/debit card).  FORMCHECKBOX  I am requesting to be notified of the replacement supply due to be picked up during regular daytime business hours. I agree to call ahead to verify that all supplies are in stock and ready for pick-up. I understand that my portion of the supplies is due upon receipt.  FORMCHECKBOX  Notify me by phone:  FORMTEXT       ( FORMCHECKBOX cell  FORMCHECKBOX home  FORMCHECKBOX other)  FORMCHECKBOX  Send an e-mail to this address:  FORMTEXT       _____________________________________________________ ________ Patient / Customer Signa*,.8:>BZ\prt~🖅rfWE#h90h:5CJOJQJ^JaJh:5CJOJQJ^JaJhq9h:>*CJaJ%jhq9>*CJUaJmHnHu jvhq9>*CJUaJhq9>*CJaJjhq9>*CJUaJh2CJaJ%jh0Z>*CJUaJmHnHu jh0Z>*CJUaJh0Z>*CJaJjh0Z>*CJUaJhq9CJaJhpsCJaJ8 : =>CO`x $d$Ifa$$a$$a$ gd 6 8 : V W _ i z T h s  κ~~~p~~~~~^L#h9hu5CJOJQJ^JaJ#heh:5CJOJQJ^JaJhn5CJOJQJ^JaJhn'CJOJQJ^JaJhXCJOJQJ^JaJh:CJOJQJ^JaJ#heh:5CJOJQJ^JaJ&hkhk56CJOJQJ^JaJ h0Z56CJOJQJ^JaJ hk56CJOJQJ^JaJh:5CJOJQJ^JaJ ;<=>BCNxyz˻ˮl\LA1jh)@OJQJU^JaJh:5OJQJ^Jh:5B*OJQJ^Jphh)@5B*OJQJ^Jph,h)@h:5B*CJOJQJ^JaJph,h)@h)@5B*CJOJQJ^JaJph&heh956CJOJQJ^JaJh:56OJQJ^Jhuhu56OJQJ^Jhuh:56OJQJ^J#h9hu5CJOJQJ^JaJ#h9h:5CJOJQJ^JaJxyYJAA2$d$Ifa$gd.-Z d$If$d$Ifa$gd)@kd$$IfTl\$ l%H t0d&44 laytTz"#1234A^z{¶£~zdzNz+jfh3B6h)@OJQJU^JaJ+j)h3B6h)@OJQJU^JaJh)@+jh3B6h)@OJQJU^JaJh3B6h)@OJQJ^JaJ%jh3B6h)@OJQJU^JaJh.-ZOJQJ^JaJh:OJQJ^JaJjh)@OJQJU^JaJ+jh)@h:OJQJU^JaJh)@OJQJ^JaJ!WKBB3$d$Ifa$gd.-Z d$If $$Ifa$gd)@kd#$$IfTl\$ l%H t0d&44 laytT!"4AjyWKBB3$d$Ifa$gd.-Z d$If $$Ifa$gd)@kd`$$IfTl\$ l%H t0d&44 laytTyzWKBB3$d$Ifa$gd.-Z d$If $$Ifa$gd)@kd$$IfTl\$ l%H t0d&44 laytT+WKBB3$d$Ifa$gd.-Z d$If $$Ifa$gd)@kd$$IfTl\$ l%H t0d&44 laytT,-;<=>ַƎieYַC+jZ h3B6h)@OJQJU^JaJh2OJQJ^JaJh2+j h3B6h2OJQJU^JaJh3B6h2OJQJ^JaJ%jh3B6h2OJQJU^JaJ+jh3B6h)@OJQJU^JaJh3B6h)@OJQJ^JaJh)@OJQJ^JaJh)@%jh3B6h)@OJQJU^JaJ+jh3B6h)@OJQJU^JaJ+,>GpWKBB3$d$Ifa$gd.-Z d$If $$Ifa$gd)@kd$$IfTl\$ l%H t0d&44 laytTWK??0$d$Ifa$gdj( d$Ifgdj( $$Ifa$gdj(kdT$$IfTl\$ l%H t0d&44 laytT,WKBB3$d$Ifa$gd.-Z d$If $$Ifa$gd)@kd $$IfTl\$ l%H t0d&44 laytT'+-.<=>?EFMYnoz|}ưաyfWfHfh0Z>*CJaJmHnHuh0Z5>*CJOJQJ^J%jh0Z5>*CJOJQJU^JhN3h:5CJOJQJ^JheCJOJQJ^Jh2OJQJ^JaJh3B6h)@OJQJ^JaJ+j h3B6h.-ZOJQJU^JaJh3B6h.-ZOJQJ^JaJ%jh3B6h.-ZOJQJU^JaJh)@OJQJ^JaJh.-ZOJQJ^JaJ,-?No{WKBB3$d$Ifa$gd.-Z d$If $$Ifa$gd)@kd $$IfTl\$ l%H t0d&44 laytT{|}abWRMER8 P^`Pgde$a$gdN3gdN3$a$kd $$IfTl\$ l%H t0d&44 laytTabcqrsu*㌟|o_R_R_BRB_hehe56OJQJ^Jh.56OJQJ^Jheh:56OJQJ^Jh.5CJOJQJ^Jh.h:5CJOJQJ^J%j h:CJOJQJU^Jjh:CJOJQJU^J hXh:CJOJQJ^JaJheh:OJQJ^JhN3OJQJ^JhN3CJOJQJ^Jh:CJOJQJ^Jh0Zh0Z5CJOJQJ^J*+,.M&(<=>?@NOPQ^cdefzkXLL:"jhqAX>*CJOJQJU^Jh.CJOJQJ^J%j h:CJOJQJU^JhXheCJOJQJ^JhXh:CJOJQJ^JhkCJOJQJ^JhXhN3CJOJQJ^JhXh.CJOJQJ^Jh.5CJOJQJ^Jh.h:5CJOJQJ^Jh:CJOJQJ^Jjh:CJOJQJU^J%jH h:CJOJQJU^J?.02;H=H>H@HAHCHDHFHGHIHJHHHHH36$a$ p@ ^`$a$ $xa$gdefpq  246@B^`bln˴˥zdzzNzz8+jh.hj(CJOJQJU^J+jh.hj(CJOJQJU^J+jh.hj(CJOJQJU^Jjh.CJOJQJU^Jh.CJOJQJ^JhhCJOJQJ^JhhqAXCJOJQJ^J-jhqAX>*CJOJQJU^JmHnHu"jhqAX>*CJOJQJU^J(j0hqAX>*CJOJQJU^JhqAX>*CJOJQJ^J&(*,.02㸦mbTJh:OJQJ^Jh:CJOJQJ^JaJh:6OJQJ^J-jhqAX>*CJOJQJU^JmHnHu(jthqAX>*CJOJQJU^JhqAX>*CJOJQJ^J"jhqAX>*CJOJQJU^Jh:CJOJQJ^JhCJOJQJ^J%jh.CJOJQJU^Jh.CJOJQJ^Jjh.CJOJQJU^JH;HH?HAHBHDHEHGHHHJHKHXHYH|H}HHHHHHHHHHHHHŷh_6CJaJh36CJaJmHnHuh36CJaJjh36CJUaJh3jhE!h35CJ4UhVjhVUUh:CJOJQJ^Jh:>*CJOJQJ^Jture Date TPSC Staff Signature       FILENAME \p 2011DME Supply Replacement Auth.doc Created on  CREATEDATE \@ "M/d/yyyy h:mm:ss am/pm" 4/27/2011 4:50:00 PM 21:p/ =!"#$% vD@ptnametDText3$$If!vh555H5 #v#v#vH#v :V l t0d&555H5 ytTtDeCheck5$$If!vh555H5 #v#v#vH#v :V l t0d&555H5 ytTtDeCheck5$$If!vh555H5 #v#v#vH#v :V l t0d&555H5 ytTtDeCheck5$$If!vh555H5 #v#v#vH#v :V l t0d&555H5 ytTtDeCheck5$$If!vh555H5 #v#v#vH#v :V l t0d&555H5 ytTtDeCheck5$$If!vh555H5 #v#v#vH#v :V l t0d&555H5 ytTtDeCheck5$$If!vh555H5 #v#v#vH#v :V l t0d&555H5 ytTtDeCheck5$$If!vh555H5 #v#v#vH#v :V l t0d&555H5 ytTtDeCheck5$$If!vh555H5 #v#v#vH#v :V l t0d&555H5 ytTtDeCheck5$$If!vh555H5 #v#v#vH#v :V l t0d&555H5 ytTtDeCheck1tDeCheck2tDeCheck3tDText4tDeCheck6tDeCheck7tDeCheck8tDeCheck4tDText5/Ddd  2F+3AI ??"`bwn&iʮTg/}S, nKn&iʮTg/}PNG  IHDR v) sRGB pHYs+IDATx^|]Eǟē hqwX`eYa⮥hB)F{r,/m>irܙ3g~̱q߻?))e/KKKKO۝޹mg]rss,n7HӶQKIHwھ+%9%7ς{6"(`ELc+iE#Ch5jRR5Q{km;VKKVC f@-,Z,ٶch5jRR5Q{km;VKKVC f@-,Z,ٶch5jRR5Q{km;VKKVC f@-,Z,ٶch5jRR5Q{km;VKKVC f@-,Z,ٶch5jRR5Q{km;VKKVC f@-,Z,ٶch5jRR5Q{km;VKKVC f@-,Z,ٶch5jRR5Q{km;VKKVC f@-,Z,ٶch5jRR5Q{km;VKKVC f@-,Z,ٶc.7_ڀCڳ6,=._4Yjɷ[ G]~Q{WQ Q^+5%5===99,5[[ PsT򺼖>Oww{…SߚzjP^~v<{ԟCv6SZNz(^ NLpgA${g|1'n߱==#]wL|&jm=TxRSSSSRRRST~KM$o>/=(旀rHvv3ZLSOwھ n˭ކr}=F:w\RTАom[ TCGX|bap ORcVFS3RdIIOx=riE)<^/WM nǗ\VZ60vXn|n&a)ސ@"{$%5_֧w Eyy9KȺp; 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