New West Medical, Inc. - Online Order Form

In order to reduce risk of infection, as well as ensure proper functioning of your equipment, your insurance recommends replacing your disposable supplies according to the schedule below.
Supplies Mask Nasal Replacement Cushion Pillow Replacement Cushion Full Face Cushion Chinstrap Headgear Filter, Fine Disposable Tubing Liberty Mouth Cushion Liberty Nasal Pillow	Insurance Recommends 1 per 3 months 2 per month 2 per month 1 per month 1 per 6 months 1 per 6 months 2 per month 1 per 3 months 1 per month 1 per month
Insurance companies pay for these disposable items according to the manufacturer's recommended replacement schedule. Please contact us if you have any questions about what you are eligible for. Please indicate what supplies are needed by checking the boxes below. Please sign and date this letter and return in the pre-paid envelope. Your disposable items will be shipped out shortly. Include your email address below for delivery status and tracking. If you have any questions place a call to New West Medical at 530.221.5864.

Full face mask	Nasal mask	Pillow system mask
Tubing	Disposable filters	Non-disposable filters
Headgear	Chin strap	Cushions
Liberty Mouth Cushion	Liberty Nasal Pillow Cushion
Send all recommended supplies
I would like to schedule a visit with your respiratory clinician.
Please make a selection. * required
Date:
Email:
First Name: Last Name:
Phone #:
Date of Birth:
Mailing Address:
*Enter Code


9714 Tanqueray Court • Redding, CA 96003 530.221.5864 • Fax 530.221.1474 • jwilbur@newwestmedical.com