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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  10. Invalid Input
  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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  20. Invalid Input
  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*
    Invalid Input
  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. Has the physician prescribed apnea and hypopnea definitions?


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  57. Apnea %*
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  58. Apnea Duration*
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  59. Hypopnea %*
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  60. Hypopnea Duration*
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  61. Auto-OFF*
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  62. Auto-ON*
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  63. Mask Fit Check*
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  64. Notifications*
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  65. Low (Standby) Backlight*
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  66. Quick View Menu*
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  67. Delay Time Lockout*
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  68. Tubing Length Lockout
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  69. Auto-ON/OFF*
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  70. SmartFlex Lockout*
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  71. Operating Mode*
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  72. CPAP Pressure*
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  73. Upper Pressure Limit (UPL)*
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  74. Lower Pressure Limit (LPL)*
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  75. Delay Time*
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  76. Delay Pressure*
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  77. Pressure Unit*
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  78. Tubing Length*
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  79. Low Use Threshold*
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  80. SmartFlex*
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  81. SmartFlex Mode*
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  82. SmartFlex IPAP Rounding*
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  83. SmartFlex EPAP Rounding*
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  84. Has the physician prescribed apnea and hypopnea definitions?


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  85. Apnea %*
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  86. Apnea Duration*
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  87. Hypopnea %*
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  88. Hypopnea Duration*
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  89. Auto-OFF*
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  90. Auto-ON*
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  91. Mask Fit Check*
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  92. Notifications*
    Invalid Input
  93. Low (Standby) Backlight*
    Invalid Input
  94. Quick View Menu*
    Invalid Input
  95. Delay Time Lockout*
    Invalid Input
  96. Tubing Length Lockout
    Invalid Input
  97. Auto-ON/OFF*
    Invalid Input
  98. SmartFlex Lockout*
    Invalid Input
  99. Operating Mode
    Invalid Input
  100. IPAP Pressure*
    Invalid Input
  101. EPAP Pressure*
    Invalid Input
  102. Delay Time*
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  103. Delay Pressure*
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  104. IPAP Rounding*
    Invalid Input
  105. EPAP Rounding*
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  106. Inhale Trigger Sensitivity*
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  107. Exhale Trigger Sensitivity*
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  108. CPAP Pressure*
    Invalid Input
  109. Pressure Unit*
    Invalid Input
  110. Tubing Length*
    Invalid Input
  111. Low Use Threshold*
    Invalid Input
  112. Auto-OFF*
    Invalid Input
  113. Auto-ON*
    Invalid Input
  114. Mask Fit Check*
    Invalid Input
  115. Notifications*
    Invalid Input
  116. Low (Standby) Backlight*
    Invalid Input
  117. Delay Time Lockout*
    Invalid Input
  118. Tubing Length Lockout
    Invalid Input
  119. Rounding Lockout*
    Invalid Input
  120. Triggering Lockout*
    Invalid Input
  121. Auto-ON/OFF*
    Invalid Input
  122. Operating Mode
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  123. IPAP*
    Invalid Input
  124. EPAP*
    Invalid Input
  125. Max IPAP*
    Invalid Input
  126. Min EPAP*
    Invalid Input
  127. Pressure Support*
    Invalid Input
  128. CPAP Pressure*
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  129. Delay Time*
    Invalid Input
  130. Delay Pressure*
    Invalid Input
  131. IPAP Rounding*
    Invalid Input
  132. EPAP Rounding*
    Invalid Input
  133. Inhale Trigger Sensitivity*
    Invalid Input
  134. Exhale Trigger Sensitivity*
    Invalid Input
  135. Pressure Unit*
    Invalid Input
  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. Has the physician prescribed apnea and hypopnea definitions?


    Invalid Input
  143. Apnea %*
    Invalid Input
  144. Apnea Duration*
    Invalid Input
  145. Hypopnea %*
    Invalid Input
  146. Hypopnea Duration*
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  147. Auto-OFF*
    Invalid Input
  148. Auto-ON*
    Invalid Input
  149. Mask Fit Check*
    Invalid Input
  150. Notifications*
    Invalid Input
  151. Low (Standby) Backlight*
    Invalid Input
  152. Quick View Menu*
    Invalid Input
  153. Delay Time Lockout*
    Invalid Input
  154. Tubing Length Lockout
    Invalid Input
  155. Rounding Lockout*
    Invalid Input
  156. Triggering Lockout*
    Invalid Input
  157. Auto-ON/OFF*
    Invalid Input
  158. SmartFlex Lockout*
    Invalid Input
  159. Terms and Conditions*
    Please review the terms and conditions
  160. Your Name*
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  161. Your Email*
    Invalid Input
  162. Name of Provider*
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  163. Comments
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  164.   
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