New Patients In order to become a patient, please fill out the information below and upload the necessary documentation. A Quality DME team member will contact you within the next business day. We will initiate contact with your insurance company to verify eligibility and benefits, and start any necessary authorizations. Once the insurance authorization is complete, we will contact you to schedule your equipment to be delivered. Please be sure to review our insurance acceptance list prior to completing this form. View Insurance List 1 General Info2 Insurance3 Documentation General InfoHow did you hear about Quality DME?*Search engine queryReview site like Yelp! or similarSocial media (Facebook, Instagram, Twitter, LinkedIn)Healthcare provider or professionalFriends, family, or a co-workerEmail NewsletterFirst Name*Last Name*Primary Phone Number*Date of Birth* MM DD YYYY Email Address* Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code InsurancePrimary Insurance Provider*Primary Insurance ID #*Primary Insurance Group #*Primary Insurance Policy Holder*Primary Insurance Policy Holder Date of Birth* MM DD YYYY Secondary InsuranceWould you like to add a Secondary Insurance?YesNoSecondary Insurance Provider*Secondary Insurance ID #*Secondary Insurance Group #*Secondary Insurance Policy Holder*Secondary Insurance Policy Holder Date of Birth* MM DD YYYY Referring Physician* DocumentationTo better serve you, please submit the following:1. Prescription (Required) A copy of a prescription from your physician. In addition to your name and the requested equipment, it must include diagnosis and length of need. Must be signed by a physician.2. Sleep Study: Baseline PSG A copy of your original sleep study which diagnosed your sleep apnea. It may have been in a diagnostic facility, or a home sleep test (HST). Must be signed by a physician.3. Sleep Study: Titration report A copy of your titration sleep study report done in a diagnostic facility. Not all patients will have a titration. Must be signed by a physician.File 1 (Prescription)*Accepted file types: pdf.**PDFs Only**File 2 (Sleep Study: Baseline PSG)Accepted file types: pdf.**PDFs Only**File 3 (Sleep Study: Titration report)Accepted file types: pdf.**PDFs Only**NotesPlease add any additional information. Things we’d like to know: -If you received a machine previously, the date which it was provided -If you want Quality DME to become your resupply provider, please provide us with the make and model of your current equipment -If you have questions about your equipment, tell us what they are
