PAP refill and change request form
Please use the online form below to request a refill, add a new medication, make changes to medications, or update your contact information.
Once an email address is submitted, the form page will load. The form can be filled out and signed digitally on that page. Upon completion, the form will be sent to your email address.
The online form is not available to Maine and Minnesota residents. For more information, see how to apply by paper.
Download the application for your patient's state below to apply.
To finish, please add your e-signature to the Adobe Sign form below.
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Please try again later, or download a PDF instead.
You can also call us for help at 1‑866‑310‑7549, Monday‑Friday, 8:00 am‑8:00 pm ET.
PAP refill and change request form submitted and sent to your email
If you’d like, you can also download a copy of the signed form below.
Completed PAP refill and change request form
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Call 1‑866‑310‑7549 available Monday‑Friday, 8:00 am‑8:00 pm ET for help.