IntelliPAP TouchFree Delivery Program Form
  1. Instructions

      Please contact Customer Service immediately with any changes to this order as orders are processed immediately. You can reach Customer Service at cs@DeVilbisshc.com or 1-800-338-1988.

      1. Customer must complete the IntelliPAP TouchFree Delivery Program Commitment Form to take part in this program.
      2. Read the Return and Warranty Policy Terms and Conditions and the Business Associate Agreement below. You cannot submit the Form below without reviewing and agreeing to these Terms and Conditions, including the Business Associate Agreement.
        1. All claims submitted will be processed and shipped within 24 hours during the work week (Monday – Friday). Orders placed on Friday will ship on Monday.
        2. Prescription information may be added to the device to customize each unit for the patient. If you do not provide prescription settings, the replacement IntelliPAP will be shipped with factory default settings.

      NOTE:

      • All units are shipped via UPS Ground delivery. Other shipping options are available below for an additional fee.
  2. All fields marked with a red asterisk are required fields.

  3. Dealer Contact Information

  4. Date*
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  5. Account Number*
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  6. PO Number*
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  7. Dealer/Company Name*
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  8. Contact Name*
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  9. Dealer Address*
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  11. City*
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  12. State*
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  13. ZIP*
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  14. Phone*
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  15. Email*
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  16. Fax*
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  17. Patient Shipping Information

    Please enter the shipping information for your patient.
  18. Name*
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  19. Address*
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  21. City*
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  22. State*
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  23. ZIP*
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  24. Phone
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  25. Shipping Method



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  26. Product Information

  27. IntelliPAP Model*
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  28. Invalid Input
  29. Invalid Input
  30. Invalid Input
  31. Invalid Input
  32. Do you require us to set the prescription settings on this device?*


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  33. Device Settings

    The Device Settings listed below are Standard Factory Settings. If you are unsure of a specific setting for the patient, please do not adjust the settings below.

  34. Language*
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  35. CPAP Pressure*
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  36. Delay Time*
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  37. Delay Pressure*
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  38. Pressure Unit*
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  39. Low Use Threshold*
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  40. Auto-OFF*
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  41. Auto-ON*
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  42. Notifications*
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  43. Low (Standby) Backlight*
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  44. Delay Time Lockout*
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  45. Auto-ON/OFF*
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  46. CPAP Pressure*
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  47. Delay Time*
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  48. Delay Pressure*
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  49. Pressure Unit*
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  50. Tubing Length*
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  51. Low Use Threshold*
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  52. SmartFlex*
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  53. SmartFlex Mode*
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  54. SmartFlex IPAP Rounding*
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  55. SmartFlex EPAP Rounding*
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  56. Auto-OFF*
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  57. Auto-ON*
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  58. Mask Fit Check*
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  59. Notifications*
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  60. Low (Standby) Backlight*
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  61. Quick View Menu*
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  62. Delay Time Lockout*
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  63. Tubing Length Lockout
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  64. Auto-ON/OFF*
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  65. SmartFlex Lockout*
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  66. Do you want to adjust the advanced settings?


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  67. Advanced Settings

  68. Apnea %*
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  69. Apnea Duration*
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  70. Hypopnea %*
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  71. Hypopnea Duration*
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  72. Operating Mode*
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  73. CPAP Pressure*
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  74. Lower Pressure Limit (LPL)*
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  75. Upper Pressure Limit (UPL)*
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  76. Delay Time*
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  77. Delay Pressure*
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  78. Pressure Unit*
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  79. Tubing Length*
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  80. Low Use Threshold*
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  81. SmartFlex*
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  82. SmartFlex Mode*
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  83. SmartFlex IPAP Rounding*
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  84. SmartFlex EPAP Rounding*
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  85. Auto-OFF*
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  86. Auto-ON*
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  87. Mask Fit Check*
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  88. Notifications*
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  89. Low (Standby) Backlight*
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  90. Quick View Menu*
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  91. Delay Time Lockout*
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  92. Tubing Length Lockout
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  93. Auto-ON/OFF*
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  94. SmartFlex Lockout*
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  95. Do you want to adjust the advanced settings?


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  96. Advanced Settings

  97. Apnea %*
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  98. Apnea Duration*
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  99. Hypopnea %*
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  100. Hypopnea Duration*
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  101. Operating Mode
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  102. EPAP Pressure*
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  103. IPAP Pressure*
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  104. EPAP Rounding*
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  105. IPAP Rounding*
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  106. Inhale Trigger Sensitivity*
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  107. Exhale Trigger Sensitivity*
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  108. CPAP Pressure*
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  109. Delay Time*
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  110. Delay Pressure*
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  111. Pressure Unit*
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  112. Tubing Length*
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  113. Low Use Threshold*
    Invalid Input
  114. Auto-OFF*
    Invalid Input
  115. Auto-ON*
    Invalid Input
  116. Mask Fit Check*
    Invalid Input
  117. Notifications*
    Invalid Input
  118. Low (Standby) Backlight*
    Invalid Input
  119. Delay Time Lockout*
    Invalid Input
  120. Tubing Length Lockout
    Invalid Input
  121. Rounding Lockout*
    Invalid Input
  122. Triggering Lockout*
    Invalid Input
  123. Auto-ON/OFF*
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  124. Operating Mode
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  125. Max IPAP*
    Invalid Input
  126. Min EPAP*
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  127. Pressure Support*
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  128. CPAP Pressure*
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  129. Delay Time*
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  130. Delay Pressure*
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  131. EPAP Rounding*
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  132. IPAP Rounding*
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  133. Exhale Trigger Sensitivity*
    Invalid Input
  134. Inhale Trigger Sensitivity*
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  135. Pressure Unit*
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  136. Tubing Length*
    Invalid Input
  137. Low Use Threshold*
    Invalid Input
  138. SmartFlex*
    Invalid Input
  139. SmartFlex Mode*
    Invalid Input
  140. SmartFlex IPAP Rounding*
    Invalid Input
  141. SmartFlex EPAP Rounding*
    Invalid Input
  142. Auto-OFF*
    Invalid Input
  143. Auto-ON*
    Invalid Input
  144. Mask Fit Check*
    Invalid Input
  145. Notifications*
    Invalid Input
  146. Low (Standby) Backlight*
    Invalid Input
  147. Quick View Menu*
    Invalid Input
  148. Delay Time Lockout*
    Invalid Input
  149. Tubing Length Lockout
    Invalid Input
  150. Rounding Lockout*
    Invalid Input
  151. Triggering Lockout*
    Invalid Input
  152. Auto-ON/OFF*
    Invalid Input
  153. SmartFlex Lockout*
    Invalid Input
  154. Do you want to adjust the advanced settings?


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  155. Advanced Settings

  156. Apnea %*
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  157. Apnea Duration*
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  158. Hypopnea %*
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  159. Hypopnea Duration*
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  160. Terms and Conditions*
    Please review the terms and conditions
  161. Your Name*
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  162. Your Email*
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  163. Name of Provider*
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  164. Comments
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  165.   
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