RHC - Change of Address Form

Patient Contact Details Change Request Form
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Patient ID
What would you like to update today? Select all that apply.*

Phone NumberEmailAddress
Previous Number
Please enter best contact number for us to reach you.
New Phone Number
Please enter best contact number for us to reach you.
Previous Email
example@example.com
New Email
example@example.com
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this Address Change Permanent or Seasonal?

PermanentSeasonal
What's Next?

Once we receive your completed Change Request Form, we will update your information in our system. If we have any questions or need additional information, a member of our team will reach out to you directly.
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 Contact Details Change Request Form

What's Next?