SYNCLARA Cough System Supply Order Form

Fill out the form below and a member of the Baxter Respiratory Health team will be in contact with you.

You understand that providing this information is your request to reorder your supplies. Your order will be processed on your next delivery date cycle with the same circuit supplies and sizes as previously ordered.

Patient Name*

Patient Date of Birth (MM/DD/YYYY)*

Patient Address*

City*

State*

Zip Code*

How many uses are left on your supply?*

How many treatments are you doing per 24-hour period/day?*

Please complete the below section if there have been any changes to the below information:

Insurance

Insurance Provider

Insurance ID Number

Subscriber Name

Subscriber Date of Birth (MM/DD/YYYY)

Patient/Caregiver Contact Information

Billing Address

City

State

Zip Code

Phone Number

Pulmonologist/Neurologist

Name

Facility Name

Provider Type

Phone

Each order requires insurance verification/eligibility and possible preauthorization to determine any out-of-pocket copays or deductibles, which may delay the shipping process.

Telephone: 800-426-4224 option 3, then option 1.

*required

Respiratory Health

Advancing respiratory health through innovative therapies

Hill-Rom® Respiratory Care