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CPAP Donation Form for Assistance Program

The American Sleep Apnea Association operates a CPAP Assistance Program (C.A.P.) that accepts donations of gently used CPAP machines to provide to those unable to afford treatment. Donors are asked to fill out a form with their contact information, details about the machine being donated such as the manufacturer, model, and estimated usage, and any accompanying accessories. The form should then be faxed to C.A.P. at the provided number where they will provide shipping instructions for getting the donated machine to them so it can be redistributed to help others manage their sleep apnea.

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39 views1 page

CPAP Donation Form for Assistance Program

The American Sleep Apnea Association operates a CPAP Assistance Program (C.A.P.) that accepts donations of gently used CPAP machines to provide to those unable to afford treatment. Donors are asked to fill out a form with their contact information, details about the machine being donated such as the manufacturer, model, and estimated usage, and any accompanying accessories. The form should then be faxed to C.A.P. at the provided number where they will provide shipping instructions for getting the donated machine to them so it can be redistributed to help others manage their sleep apnea.

Uploaded by

flyboyfreud
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

CPAP ASSISTANCE PROGRAM

of the

American Sleep Apnea Association


6856 Eastern Avenue, NW Suite 203 Washington, DC 20012 Telephone: 888-293-3650 Facsimile: 888-293-3650

Donation Evaluation Form


Dear Donor:
If you have a new or gently used CPAP machine you wish to donate to the CPAP Assistance Program (C.A.P.),
please fill in the following form and fax to us at 888-293-3650.
We will be in touch with shipping instructions. If you have questions, please telephone C.A.P. at
1-888-293-3650 or include them in the comment box.

Name: __________________________________________________________________________
Street Address: ___________________________________________________________________
City: __________________________________ State: ____________ Zip code: _______________
Email: ________________________________________________ Phone #: __________________
Machine Manufacturer: _____________________________________________________________
Model: _________________________ Approximate Age of Machine: ________________________
Hours Used (estimate or give months of use if you dont know exactly): ______________________
Accompanying Accessories (carry cases, unopened packages of filter, etc.): ___________________
_________________________________________________________________________________
Comments:

CAP Donor

Page 1

Revised: 6/12

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