Care Transfer Form

Care Transfer Form
To be completed by patients who wish to transfer to a new PAP Supply Company.
Patient Name*
Patient DOB*
Phone Number*
Previous PAP Supply Company*
New PAP Supply Company: CPAP Services, LLC
Date*

MonthDayYear
Date
Signature*

Clear
above*

I do not wish to receive any further supplies from my Previous PAP Supply Company namedI consent to the release of my clinical documents to CPAP Services, LLC. This includes, but is notlimited to, my PAP prescription(s), sleep studies and physician encounter notes.
Should be Empty: