Forms

Download the AffloVest Prescription Order Form and Fax Cover Sheet to submit for qualifying Cystic Fibrosis, Brochiectasis and Neuromuscluar 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.

Download
rx order check list fax cover sheet

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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medicare icd10 for airway clearance

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.

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return material authorization form