Patient Information

• Full legal name
• Date of birth
• Phone number
• Email address (if applicable)
• Current home address
• Emergency contact information

Insurance Information

Please have a copy of your insurance card(s) available.

• Primary insurance card
• Secondary insurance card (if applicable)
• Insurance policy/member ID number
• Group number (if applicable)
• Policyholder information
• Medicare or Medicaid information (if applicable)

Physician Information

• Referring physician’s name
• Physician practice or clinic name
• Office phone number
• Office fax number (if available)
• Recent visit date related to your medical need

Prescription & Medical Documentation

Some equipment requires documentation to establish medical necessity.

Please be prepared to provide:

• Physician prescription or order
• Supporting medical records (if requested)
• Recent clinical notes
• Diagnosis information
• Prior authorization documentation (if applicable)

Equipment Request Information

To ensure we provide the most appropriate solution, please tell us:

• Type of equipment requested
• Medical condition or diagnosis related to the request
• Previous equipment currently being used
• Preferred delivery location
• Any special accommodation needs

Caregiver Information (If Applicable)

If a caregiver or family member will assist with your care, please provide:

• Caregiver’s full name
• Relationship to patient
• Contact phone number
• Preferred method of communication

Home & Delivery Information

To ensure safe delivery and setup, please let us know:

• Home, apartment, or facility address
• Best delivery contact
• Accessibility concerns (stairs, elevators, gated communities, etc.)
• Preferred delivery times
• Special setup requirements