Via Christi Clinic - Working together for your good health.

Sleep Medicine Supply Order Form


Current patients can now order their supplies from Sleep Medicine Center of Kansas online!
Required fields are indicated by an asterisk (*)

*Patient First Name:   *Patient Last Name:
 
*Patient E-Mail Address:   *Patient Date of Birth:
 
*Patient Daytime Phone Number
*Supplies to Order
Mask
Disposable Filter Pack
Tubing
Headgear
Cushion/Pillow only
Water Chamber
*Delivery Preference
Pick Up Mail

Please let us know what time and location you prefer to pick up your supplies
Please allow at least one hour between the time of your request and your time of pick-up. Pick-up requests submitted after 4 pm Mon–Fri will be filled the following business day.

*

* Please select a location:
Sleep Medicine Center of Kansas East (818 N Carriage Parkway)
Sleep Medicine Center of Kansas West (750 N Socora Suite 100)

Please let us know what address to deliver your supplies to
All orders being mailed will be sent to the address specified in our system. If you need to change your mailing address, please contact us by visiting the Sleep Medicine Center of Kansas in Wichita at 818 N Carriage Parkway or by calling 316-651-2324. Mailed supplies typically arrive in two to four days from the request date.
*Address *City
*State *Zip Code

 

Additional Comments/Special Instructions

* If your insurance requires a referral (such as Preferred Plus of Kansas), one must be obtained before supplies can be dispensed.  You may obtain a CPAP supply referral by contacting your primary care physician’s referral department.  Please note that referrals can take up to 48 hours to be processed.

I understand that the replacement supplies that I have selected may not be covered by my medical insurance.  I may be required to pay for my services in full.  In the event the insurance company denied coverage, regardless of the reason, I accept responsibility for payment of my service(s) to Via Christi Clinic. 

Orders will be processed during regular business hours Monday–Friday 8 am to 5 pm. If you have any questions about online supply requests or have questions about your submission you may contact Sleep Medicine Center of Kansas at (316) 651-2324 and a member of our staff will assist you. Thank you for using online ordering!

 


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Via Christi Clinic offers urgent care on a walk-in basis to treat minor emergencies.

East Wichita
3311 E. Murdock – (316) 689-9107
Mon – Fri 8 am – 8 pm
Sat 9 am – 5 pm
Sun Noon – 5 pm
Holidays – See Immediate Care page

West Wichita
13213 W. 21st St. N – (316) 946-1789
Mon – Fri 5 pm – 8 pm
Sat 9 am – 5 pm
Sun Noon – 5 pm
Holidays – See Immediate Care page

Newton
700 Medical Center Dr. – (316) 284-5011
Mon – Fri 5 pm – 8 pm
Sat 9 am – 1 pm


Via Christi Clinic News

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Via Christi Clinic

3311 E Murdock, Wichita, KS 67208 — 316-689-9111

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