Forms
Download the AffloVest Prescription Order Form and Fax Cover Sheet to submit for qualifying Cystic Fibrosis, Bronchiectasis and Neuromuscular orders.
AffloVest Order Form
Use this simple Medicare checklist to determine whether your patients meet the guidelines for Medicare, Medicaid and Private insurance reimbursement. Use the Prescription form on the back to place an AffloVest Order.
AffloVest Fax Cover Sheet
Use this Fax Cover Sheet when submitting orders to AffloVest to ensure all patient and order information is submitted correctly and in a timely manner.
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Durable Medical Provider Forms
Return Material Authorization Form
This form is for DME use to return or exchange AffloVest for any warranted repair or size exchanges.
