New Patients

New Patients Submission Form

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 Info

2 Insurance

3 Documentation

General Info
Name*
First Last
Date of Birth*
MM
DD
YYYY
Primary Phone Number*
Email Address*
Home Address*
Street Address Address Line 2 City State ZIP Code

Insurance
Primary Insurance Provider*
Primary Insurance ID #*
Primary Insurance Group #*
Primary Insurance Policy Holder*
Primary Insurance Policy Holder Date of Birth*
MM
DD
YYYY
Secondary Insurance
Would you like to add a Secondary Insurance?
- Yes
- No
Secondary Insurance Provider*
Secondary Insurance ID #*
Secondary Insurance Group #*
Secondary Insurance Policy Holder*
Secondary Insurance Policy Holder Date of Birth*
MM
DD
YYYY
Referring Physician*

Documentation
To 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.
Upload File*
Drop files here or

Accepted file types: doc, docx, xls, ppt, pdf.
Notes
Please 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

New Patients Submission Form

General Info

Insurance

Documentation

1. Prescription (Required)

2. Sleep Study: Baseline PSG

3. Sleep Study: Titration report

Contact Us

Fairfax, VA – Main Office

Columbia, MD

Fredericksburg, VA

Links

New Patients Submission Form

General Info

Insurance

Documentation

1. Prescription (Required)

2. Sleep Study: Baseline PSG

3. Sleep Study: Titration report

Footer

Contact Us

Fairfax, VA – Main Office

Columbia, MD

Fredericksburg, VA

Links