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
Order Form

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.

Download
medicare icd10 for airway clearance

Business Forms for DME Providers:

AffloVest RMA Form

Use this fillable PDF form to begin an AffloVest return or size exchange.

Download
Afflovest RMA Form

Customer Information Form

Use this fillable form to provide contact information for your business.

Download
New Customer Info Form

Credit Application

Use this fillable form to apply for credit with us.

Download
Credit Application