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NEB CUP REORDER
NEB KIT ORDER
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Pay Here
Providers
Patients
Products
Respiratory Products
Nebulizer Systems
OPEP Systems
Nebulizer Sets
Masks
Chambers
Peak Flow Meters
Pulse Oximeters
Accessories
Breast Pumps
Phototherapy
Order
NEB CUP REORDER
NEB KIT ORDER
Support
Company
Mission
Locations
0
Items :
0
Subtotal :
$
0.00
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Neb Cup Reorder
(Neb cups should be replaced every six months)
This order is for two reusable neb cups and tubing - a one year supply!
Your Information
Patient First Name
*
Patient Last Name
*
Patient Middle Initial
Gender
*
Male
Female
Date of Birth
*
Month
Day
Year
Parent / Guardian First Name
Parent / Guardian Last Name
Street Address
*
Apt. / Unit #
City
*
State
*
District of Columbia
Georgia
Indiana
Kentucky
Maryland
North Carolina
Ohio
South Carolina
Tennessee
Texas
All Other States (Self Pay Only)
Zip Code
*
Email
*
Phone
*
Do You Have a Prescription?
I have a prescription for neb cups
*
Yes
No
Please upload a copy of your prescription here
Max. file size: 32 MB.
Physician's Practice or Clinic Name
*
Prescribing Physician's Name
*
Clinic Phone Number
*
Insurance Information
Insurance Name
*
Insurance Phone Number
*
Member ID (Letters and Numbers)
*
Group #
*
Relationship to Patient
*
Select Desired Nebulizer System
This will let us know which neb cups/components to send you.
My compressor is:
*
DRIVE SportNeb 2 (ADULT)
DRIVE SportNeb2 (PEDIATRIC)
DRIVE Character Nebulizer
PHILIPS RESPIRONICS Character Nebulizer
MONAGHAN Ombra
PARI Trek S
PARI Vios PRO
PARI Vios (ADULT)
PARI Vios (PEDIATRIC)
Please read and sign:
I hereby authorize Neb Doctors (herein referred to as “Provider”) to provide the equipment prescribed above and understand that Provider is an independent company and not part of any medical practice, hospital, or any other company.
I certify that the information provided by me above in applying for payment under title XVII (Medicare) of the Social Security Act or any other insurance benefits is true and correct.
I understand that I am personally responsible to Provider for balance not paid in full by insurance coverage, whether applied to deductible or co-pay responsibilities or, in the absence of insurance coverage, the total balance. The portions of any bill for which I am responsible are due upon invoice receipt from Provider. I must pay charges outstanding within 30 days of the first invoice received. Should Provider refer my account to a collection agency or attorney for collection, I agree to pay all collection costs allowed by law, including but not limited to court costs and attorney fees of 30% of my bill. I understand that all delinquent accounts shall bear interest at the rate of 12% per annum.
I agree that Provider may contact me via telephone, email, USPS, or text to facilitate my order and payment, remind me about maintenance items, and alert me to new products and promotions.
I have been instructed on the proper and safe use of the above-listed equipment.
Patient received privacy policy.
Please check box to agree:
*
I certify that I have read the terms and conditions of this agreement, any attachments and agree to its content.
