REF WI 8.1-809
30-DAY MASK SATISFACTION PROMISE PROGRAM
Mask Replacement Request Form
Purchaser Name: / Enter purchaser name / Ship-to Account Number: / Enter ship-to number
Purchaser Contact Name: / Enter contact name / Company Phone Number: / Enter phone number
Purchaser
Ship-to Address: / Enter ship-to address / Company Fax Number: / Enter fax number
City, State: / Enter City, State / Zip Code: / Enter zip code
Today's Date: / Enter Date / Purchase Order: (optional)
*Separate POs need separate forms / Enter PO number

Original mask placed on patient:

FULL FACE MASKS
Amara Silicone
P Enter Qty S Enter Qty M Enter Qty L Enter Qty
Amara Gel
P Enter Qty S Enter Qty M Enter Qty L Enter Qty
Amara View
S Enter Qty M Enter Qty L Enter Qty
ComfortGel Blue Full
S Enter Qty M Enter Qty L Enter Qty XL Enter Qty
FitLife
S Enter Qty L Enter Qty XL Enter Qty
NASAL PILLOWS MASKS
Nuance
Multi-Size Enter Qty
Nuance Pro
Multi-Size Enter Qty / NASAL MASKS
Pico
Multi-Size Enter Qty
Wisp (Multi-Size)
Fabric Enter Qty Silicone Enter Qty Pediatric Enter Qty
TrueBlue
P Enter Qty S Enter Qty M Enter Qty MW Enter Qty L Enter Qty
ComfortGel Blue
P Enter Qty S Enter Qty M Enter Qty L Enter Qty
DreamWear (Medium Frame only)
Multi-Size Enter Qty
DreamWear (Small Frame)
Cushion S Enter Qty M Enter Qty MW Enter Qty L Enter Qty
DreamWear (Medium Frame)
Cushion S Enter Qty M Enter Qty MW Enter Qty L Enter Qty
DreamWear ( Large Frame)
Cushion S Enter Qty M Enter Qty MW Enter Qty L Enter Qty
By the signature below, Purchaser certifies that it is making this request pursuant to all terms and conditions stated in the 30-Day Mask Satisfaction Promise Program Enrollment Agreement and Page 2 of this Request Form. IF PHILIPS RESPIRONICS RECEIVES THIS REQUEST FORM WITHOUT A SIGNATURE AND LEGIBLE PRINTED NAME, IT WILL BE DISCARDED WITHOUT NOTICE TO PURCHASER.
Enter Date
Purchaser Signature / Date
Enter Name / Enter Title
Print Name / Title
Email this form to (preferred) or fax to 724–387–5224.
*If you do not know your account number or need assistance with the form, please call Customer Service at 1-800-345-6443.

Program description:

Philips Respironics’ goal is to help you fit “100% of your patients, 100% of the time.” Our 30-Day Mask Satisfaction Promise Program takes our goal one step further. If a patient discontinues use of a program-approved mask* during the first 30 days of use, for fit or preference-related issues and in favor of an alternative mask, we will replace the original program-approved mask.

This Program is not to be used for masks with quality defects or breakage. For reports of masks with quality defects or breakage, contact customer service at 1-800-345-6443.

Regulatory requirements (e.g. FDA) mandate that cases of patient harm be reported by Philips Respironics. You must report such cases to customer service at 1-800-345-6443.

*Program-approved masks include:

NASAL MASKS
·  Wisp
·  TrueBlue
·  ComfortGel Blue
·  Pico
·  Dreamwear / NASAL PILLOWS MASKS
·  Nuance
·  Nuance Pro / FULL FACE MASKS
·  Amara
·  Amara Gel
·  Amara View
·  ComfortGel Blue Full
·  FitLife

Complete a Mask Replacement Request Form** for each patient who discontinues use during the first 30 days and return it to our customer service department via email (preferred) or fax.

Terms and Conditions:

·  To qualify for the Program, Purchaser must complete our "Interface and Therapy Options Overview" session, which reviews program-approved masks, or similar patient interface training/educational programing by Philips Respironics.

·  Purchaser certifies that it will only seek replacement of a program-approved mask when a patient discontinues use of the mask during the first 30 days of use for fit or preference-related issues and in favor of an alternative mask.

·  Purchaser certifies that it will comply with all applicable requirements of any third-party payer or insurer with respect to reimbursement for program-approved masks and will not seek reimbursement for the alternative mask if Purchaser received reimbursement for the original program-approved mask from any third-party payer or insurer, including any state or Federal health care program.

·  Limit one replacement mask per patient.

·  Philips Respironics reserves the right to ask for the return of the original program-approved masks.

·  Philips Respironics reserves the right to cancel the Program or modify the terms of the Program at any time.

We thank you for your continued support of Philips Respironics masks. If you have any questions, please contact Philips Respironics customer service at 1-800-345-6443.

** See page 1 for the Mask Replacement Request Form

FRM 3659 / Page 1 of 1 / Version: 17