Easy Access to All Required Repair Documents

Below are the forms patients may need when sending in CPAP machines or oxygen concentrators for repair service. Please complete the correct form before shipping your device to Fix My Oxygen. This helps our technicians begin your evaluation quickly and ensures accurate processing.

This form is for individuals sending their patient-owned CPAP machines, BiPAP devices, or other sleep therapy equipment for repair.

After submitting the form, you will receive a downloadable PDF that you can print and include with your shipment.

Use this form if:

• Your CPAP or BiPAP machine is out of warranty
• You are sending the device for CPAP repair
• You are shipping a sleep therapy device directly to a patient

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Phone *

Email *

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Make And Model of your Equipment *ResMed Air11 (includes AirCurve,AIrSense)ResMed Air11 (includes AirCurve,AirSense,AirStart)ResMed S9/VPAP

Whats Your Issue? *

Device Serial Number *

Service Options *Standard Service (3-4 Business Days)Urgent Service (1-2 Business days)Third Choice

Paragraph Text

Disclosures (Required) *

I understand that the expected turnaround time for the service option I chose is based on parts availability for my estimate.
It is the responsibility of FixMyOxygen to notify me at the time of estimation if parts are available for my repair.
If I have chosen Rush Service and parts are not available, I understand that I will be transitioned to Standard Service pricing
and turnaround times.

I understand that FixMyOxygen does not accept Medicare or any other insurance plans. We cannot inquire with any insurers
regarding eligibility of reimbursement or repair costs. I understand that FixmyOxygen does not submit claims to any
insurance company regarding repairs.

I understand it is my responsibility to pay the amount in full at the time of repair authorization. I understand that if I am
provided an estimate and decline the repair, I will be assessed a fee to return my CPAP/POC/Concentrator to me as follows:
$25 for CPAP/BiPAP machines,
$49 for portable oxygen concentrators, or
$79 for stationary oxygen concentrators to cover shipping cost and packing costs.
If I decline the repair without paying the return shipping fee, FixMyOxygen will recycle my machine at no charge to me.

After the initial repair estimate is sent, FixmyOxygen will make several reminder notifications via email and/or phone
using the contact information provided at the time of repair request. If no response has been received by FixMyOxygen
within 50 days of the initial estimate being sent, FixmyOxygen reserves the right to consider the device abandoned and
will recycle the machine.

Disclosures *

• I have read and accept the repair disclosures.

Submit

Use this form if you are sending a stationary oxygen concentrator or portable oxygen concentrator for evaluation or repair.

Please fill out the details completely, print the form, and include it in your shipping box along with your device and power supply.

Use this form if you have:

• A patient-owned stationary oxygen concentrator
• A patient-owned portable oxygen concentrator
• A device needing oxygen concentrator repair or performance evaluation

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Phone *

Email *

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Make And Model of your Equipment *Phillips Respironics Everflo or MillenniumInvacare Perfecto or Platinum (non-warranty only)Drive / DeVilbiss 525 or 1025 SeriesCAIRE Companion 5AirSep NewLife Elite/Intensity or VisionAireRhythm LM5APhillips Respironics SimplyGo/SimplyGo Mini/SimplyFloResMed MobiCAIRE Freestyle ComfortOxlife IndependenceSeQual Eclipse 5Drive iGo2AirSep Freestyle 3Inogen G3Inogen G4Inogen G5Inogen At HomeItem 18

Whats Your Issue? *

Device Serial Number *

Service Options

PORTABLE OXYGEN CONCENTRATORS (POC)

Option	Estimated Time	Cost	Return Ground Shipping
Standard Service	4–6 Business Days	$129 + Parts	FREE!
Rush Service	2–3 Business Days	$179 + Parts	FREE!

* Turnaround times are based on the time of estimate approval. Turnaround times may be longer for the CAIRE Freestyle Comfort. We apologize for the inconvenience.

STATIONARY OXYGEN CONCENTRATORS

Option	Estimated Time	Cost	Return Ground Shipping
Standard Service	6–9 Business Days	$99 + Parts	FREE!

* Turnaround times are based on the time of estimate approval. Turnaround times may be longer for the Rhythm LM5A. We apologize for the inconvenience.

Service Options *Standard Service (3-4 Business Days)Urgent Service (1-2 Business days)Third Choice

Disclosures (Required) *

I understand that the expected turnaround time for the service option I chose is based on parts availability for my estimate.
It is the responsibility of FixMyOxygen to notify me at the time of estimation if parts are available for my repair.
If I have chosen Fast Service and parts are not available, I understand that I will be transitioned to Standard Service pricing
and turnaround times.

I understand that FixMyOxygen does not accept Medicare or any other insurance plans. We cannot inquire with any insurers
regarding eligibility of reimbursement or repair costs. I understand that FixMyOxygen does not submit claims to any
insurance company regarding repairs.

I understand it is my responsibility to pay the amount in full at the time of repair authorization. I understand that if I am
provided an estimate and decline the repair, I will be assessed a fee to return my CPAP/POC/Concentrator to me as follows:
$20 for CPAP/BiPAP machines,
$40 for portable oxygen concentrators, or
$70 for stationary oxygen concentrators.
If I decline the repair without paying the return shipping fee, FixMyOxygen will recycle my device at no charge to me.

After the initial repair estimate is sent, FixMyOxygen will make several reminder notifications via email and/or phone
using the contact information provided at the time of repair request. If no response has been received by FixMyOxygen
within 45 days of the initial estimate being sent, FixMyOxygen reserves the right to consider the device abandoned and will recycle the device.

 

Disclosures *

• I have read and accept the repair disclosures.

Submit

To ensure safe and efficient processing:

• Send only the device and its power supply
• Do not include cannulas, masks, hoses, carrying cases, bags, or carts
• These items cannot be processed and may be discarded
• Use a sturdy box and reliable carrier (UPS, FedEx, etc.)
• Always include your printed form inside the package