REF WI 8.1 - 809

June 2012

30-day Mask Satisfaction Promise Program

MASK REPLACEMENT REQUEST FORM

Your company’s name: / Mitchell Home Medical / Account number: / 10100482
Contact name: / Contact phone number:
Ship-to address: / 2770 Carpenter Rd. Suite 100
City: / Ann Arbor / State/Province: / MI / Zip/Postal Code: / 48108
Today's date: / Your reference number: (optional)

NOTE: Only the masks listed below are covered under this program

Original mask placed on patient:

NASAL MASKS
TrueBlue
P S M MW L
EasyLife
P S M MW L
ComfortGel Blue
P S M L
FULL FACE MASKS
Amara
P S w/RS frame S M L
ComfortGel Blue Full
S M L XL
FullLife
S M MW L
FitLife
S L XL / NASAL PILLOWS MASKS
GoLife for Men
S M L
GoLife for Women
P S M
OptiLife
(Check all sizes that apply)
Pillows P S M L
CradleCushion S M L LN

[REQUIRED QUESTION]: Which mask did you provide to the patient as a replacement?

Manufacturer: / Mask name: / Size:

Email this form (preferred) to r fax to 724–387–5224 (US customers) or 724-387-5012 (Canadian customers).

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

*Certain terms and conditions apply

*See Reversefor 30-day Mask Satisfaction Promise Program description

FRM 3659 Page 1 of 2 Version 04

30-day Mask Satisfaction Promise Program

Program description:
Our goal is to help you fit “100% of your patients, 100% of the time.” The 30-day Mask Satisfaction Promise Program takes our intent one step further – your patient will be satisfied with our mask or we’ll replace it.
If a patient discontinues use of a program-approved mask, for fit or preference-related issues, in favor of another mask during the first 30 days of use, we will replace the original mask at no charge.
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
  • TrueBlue
  • EasyLife
  • ComfortGel Blue
NASAL PILLOWS MASKS
  • GoLife for Men
  • GoLife for Women
  • OptiLife
FULL FACE MASKS
  • Amara
  • ComfortGel Blue Full
  • FullLife
  • 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. Replacement masks will be shipped in the first week of the month following receipt of the completed form. / Terms:
  • To qualify for the Program, the customer must have completed our "Interface and Therapy Options Overview" session which reviews program-approved masks or other patient interface training/educational program by Philips Respironics
  • Limit one replacement mask per customer per patient
  • Internet sellers or distributors are not eligible to participate in the Program. Philips Respironics reserves the right to cancel the Program or modify the terms of the Program at any time
  • Philips Respironics reserves the right to ask for the return of program-approved masks
  • Customers are obligated to comply with the applicable requirements of any third-party payor or insurer with respect to reimbursement for program-approved masks
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 Reverse for the Mask Replacement Request Form

FRM 3659 Page 2 of 2 Version 04