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.Format: (000) 000-0000.
Email
example@example.com
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your shipping address the same as your billing address?
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.
Would you like us to add an "Authorized Contact" to your file?
Authorized Contact Name

First NameLast Name
Authorized Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Would you like to add an "Emergency Contact" to your account?
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Provider Information
Is the doctor who prescribed your PAP device the same as your primary care doctor?
Primary Care Doctor's Name

Dr. First NameDr. Last Name
Primary Care Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Ordering Doctor's Information Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
How would you like to provide your insurance information?
Insurance Provider
Subscriber Name
Member / Subscriber ID
Group ID (If Applicable)
Front of Insurance Card

Cancelof
Back of Insurance Card

Cancelof
Do you have a Secondary Insurance?
How would you like to provide your Secondary Insurance information?
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
Do you currently have an HSA (Health Savings Account)?
What is the HSA (Health Savings Account) Plan Name?
Sleep Therapy Treatment History
Have you ever had a CPAP or BiPAP Machine?
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.
Do you still have the PAP Machine?
When was the last time you received supplies for your PAP Machine?
Have you ever had an oral appliance for Sleep Apnea?
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?