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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.

  • Personal Information

  • Your Current Mask

  • Are you satisfied with current mask, model, and size?

      Satisfied with current mask?
  • 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

    Customer Sale and Rental Agreement
  • Customer Information Packet
  • By typing my full name below, I am providing my e-signature, and am agreeing to the terms stated in the Assignment of Benefits, Information Release, and Patient Agreement.