RHC - Sleep Therapy New Intake Form

Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter best contact number for us to reach you.
Email*
example@example.com
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized & Emergency Contacts

An Authorized Contact is a person you designate, in addition to yourself, who can communicate with us on your behalf regarding your account, your care, and supply orders. An Emergency Contact is a person you designate who we should communicate with in case you experience a medical emergency.
YesNoYes, and make this person my emergency contact as well.
Authorized Contact Name*

First NameLast Name
Authorized Contact Phone Number*
Please enter a valid phone number.
YesNo
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Provider Information
YesNoI'm not sure.
Primary Care Doctor's Name*

Dr. First NameDr. Last Name
Primary Care Doctor's Phone Number*
Please enter a valid phone number.
Primary Care Doctor's Information Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ordering Doctor's Information*

First NameLast Name
Ordering Doctor's Phone Number*
Please enter a valid phone number.
Ordering Doctor's Information Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Manual EntryUpload Card Photo
Insurance Provider*
Subscriber Name*
Member / Subscriber ID*
Group ID (If Applicable)
Front of Insurance Card*

Cancelof
Back of Insurance Card*

Cancelof
YesNo
Manual EntryUpload Card Photo
Secondary Insurance Provider*
Secondary Insurance Subscriber Name*
Secondary Insurance Member / Subscriber ID*
Secondary Insurance Group ID (If Applicable)
Please manually enter information from your secondary insurance card.*
Front of Secondary Insurance Card*

Cancelof
Back of Secondary Insurance Card*

Cancelof
YesNo
What is the HSA (Health Savings Account) Plan Name?*
Sleep Therapy Treatment History
YesNo
What insurance carrier did you have at the time you received the PAP Machine?*
What was the set up date of the previous PAP Machine?*

MonthDayYear
If you are unsure, please contact your insurance carrier.
YesNo
When was the last time you received supplies for your PAP Machine?
YesNo
What insurance carrier did you have at the time you received the oral appliance?*
List name of Insurance, examples: Medicare, Cigna
When did you receive the oral appliance?*

MonthDayYear
If you are unsure, please contact your insurance carrier.
Is there anything else you would like us to know or have any questions?
What's Next?

Once your form is submitted, we’ll begin preparing your file and will be in touch about any insurance questions and scheduling. We will try to reach you by phone and email.
Consent to Communication and Data Use:
By submitting this form, I authorize Regional Home Care and it's third party vendors to contact me via phone, email, or text message regarding my sleep therapy services and equipment needs. I understand that communications may include reminders, updates, and other information pertinent to my care.

I acknowledge that Regional Home Care will safeguard my personal information in compliance with HIPAA regulations. I understand that I may revoke this consent at any time by contacting Regional Home Care directly at optout@regionalhc.com.

By clicking "Submit," I confirm that the information provided is accurate to the best of my knowledge and I agree to the communication terms outlined above.
Should be Empty:

Patient Information

Authorized & Emergency Contacts

Provider Information

Insurance Information

Sleep Therapy Treatment History

What's Next?