Transfer of Care

Please complete this form if you are a CPAP/BIPAP user who wishes to transfer your current care to Eastern Medtech. If you have any questions or concerns please feel free to call us at (917) 793-9600. We look forward to providing you with the best possible products and services. Thank you.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone:*
Cell Phone:
Email :*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Mode of Contact

Current DME Information
Current DME Provider:*
If you cannot find your provider use the "other" field
Current DME Provider:*
Please add in a few words the reason for the transfer of care. You can dictate your information
Referral Channels*
If you cannot find your provider use the "other" field
Other Referral Channels:*

Physician Information
Primary Doctor Name:

First NameLast Name
Doctor Phone Number

Area CodePhone Number
Doctor Fax Number

Area CodePhone Number
Please select your Specialist :
Specialist Physician Name:

First NameLast Name
Specialist Phone Number

Area CodePhone Number
Point of Contact for CPAP Supplies Prescription

Primary Care PhysicianSpecialist

Preferred Contact Type & Signature
By checking this box, I authorize Eastern MedTech to contact me by Email, Text, or Phone.*

I confirm

Authorization for Release of Medical Records
Is the patient completing this form?

YesNo
Reason why Patient is not doing the form:
Name of person doing the form?

First NameLast Name
By signing below I authorize the release of medical and / or billing information to Eastern MedTech.
Patient Signature:(Depends on device, Use Mouse or Finger to Sign)*

Clear
Please verify that you are human*
Should be Empty:

Current DME Information