HIPAA authorization required: By submitting this form you confirm you are authorized to share this patient's PHI with Archway Medical for DMEPOS supply fulfillment purposes under HIPAA § 164.506 (treatment / payment / operations).

Patient First Name *

Patient Last Name *

Patient Phone *

Patient Email

Patient Date of birth *

Insurance Provider

Urgency *

Diagnosis / Clinical Justification

Referring Provider Name *

Referring Provider Practice *

Referring Provider Role *

Referring Provider Phone *

Referring Provider Email *

Referring Provider NPI

Additional Notes

I confirm I am authorized to share this patient's PHI with Archway Medical for DMEPOS supply fulfillment purposes under HIPAA section 164.506 (treatment / payment / operations).