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New Patient Referral - DME Request

Patient's Name: *

Patient DOB: *

Telephone Number (optional):

Street *

City *

State *

Zip *

Email *

Physician Name *

Physician Phone Number *

New York Recovery DME Representative that assisted you (if applicable):

Insurance Name *

Secondary Insurance (if applicable)

DME Requested (brief description) *

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Upload Insurance Card - Front

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Upload Insurance Card - Back

Permission to Communicate with New York Recovery DME
I give my permission to New York Recovery DME to contact me via text messages regarding my Durable Medical Equipment needs. I understand that this consent can be withdrawn at any time by submitting a request.

Authorization for Treatment
I confirm and authorize New York Recovery DME and its associated partners to provide, instruct on, administer, or execute the necessary treatments and services as prescribed by my physician. I acknowledge receipt of the recommended products and services.

Consent to Release Medical Information
I authorize my physician and New York Recovery DME, along with its partners, to release any pertinent medical information required by my insurance provider to process my claim.

Thank you for choosing New York Recovery DME. Your order is
being submitted to our clinical team. A member of our team will
reach out to you shortly to discuss your order.

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