RHC - Kiosk - Self Service PAP Returns

Self Service Device Dropoff ({location})
This form will guide you through the return of your PAP therapy device. Please have your device in hand before continuing as you will need to provide information from the device during submission. Completing this form will help ensure your return is processed promptly and accurately. Thank you for being part of Regional Home Care.
Full Name
Patient ID# (If Known)
Your Patient ID is located on the top right corner of your delivery ticket or Regional Home Care bill.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Email
What is the reason for the return?
How would you like to provide your device's serial number?
Serial Number (Found on the Device Label)
Photo of the Device Label Showing the Serial Number
Place the device being returned in a plastic bag and deposit it carefully in the blue return bin near this kiosk. Once this form is submitted a receipt will be emailed to the address provided. If you have questions please call customer service at 978-840-0113. Thank you and have a great day.
Signature
By signing above, I confirm the device I am returning is clean and dry; and I understand it will be subject to inspection before being accepted for return under Regional Home Care's standard return policies.
Location
Should be Empty: