Sleep Supply Enrollment Form

Home Services Sleep Supply Enrollment

Please Read! This form is exclusively for patients transitioning FROM another company TO Hometown Healthcare for sleep supplies. If you meet this criteria, please first ensure that your physician has faxed us (518-271-9973) a prescription for your sleep supplies. Once this has been done, proceed by completing the form below so we can take the final steps in welcoming you to the Hometown family! Don't hesitate to contact us with any questions you may have.

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Personal Information
First Name
Last Name
Date of Birth
Your Current PAP Therapy Information
Mask Manufacturer
Mask Model
Mask Size
CPAP/BiLevel Manufacturer
CPAP/BiLevel Model
CPAP/BiLevel Serial Number
CPAP/BiLevel Device Number (DM#)
Are you satisfied with current mask, model, and size?
- Yes No
Is there anything else you would like us to be aware of?
PLEASE REVIEW THE FOLLOWING, INDICATE THAT YOU HAVE RECEIVED THIS INFORMATION AND PROVIDE YOUR SIGNATURE TO BEGIN PROCESSING YOUR ORDER.
Click links below to view terms (You will need Adobe Reader to view these documents)
Customer Sale and Rental Agreement
Customer Information Packet
By typing my full name below, I understand that I am providing my electronic signature indicating that I understand and agree to the following:

I agree to receive electronically the documents in the Customer Information Packet: Notice of Clients Rights and Responsibilities; Notice of Privacy Practices; insurance information; complaint processes; Medicare supplier standards; Medicare Capped Rental and Purchase Information; patient safety information; return policies; and other pertinent product information.

I agree to receive electronically the Customer Sale and Rental Agreement.

I have been provided access to the Customer Information Packet and the Sale and Rental Agreement.

If I would like a paper copy of any of these documents, I will be provided one upon my request submitted to: [email protected]

I understand that I may revoke my consent to receive these documents electronically by submitting my request to: [email protected].
Full Name

Sleep Supply Enrollment Form

Personal Information

Your Current PAP Therapy Information