Transfer of Services New Patient Registration Form Name * Date of Birth * Contact Information Primary Phone * Work Phone Email * Which method would you prefer to be contacted through? Primary PhoneWork PhoneEmail Address * City * ZIP * In case of Emergency Emergency Contact Emergency Phone PCP * Sleep Doc Insurance Information Primary Insurance * Secondary Insurance Do you use a CPAP or BIPAP? * CPAP BIPAP What brand of PAP do you own? * Resmed Resprionics Other What mask interface are you currently using? * Full Face Mask Nasal Mask Nasal Pillow Mask Name of current PAP supplier * Additional Comments By checking this box, I authorize any holder, including Sleep Well, Inc of medical records information about my sleep disorder diagnosis, necessary to determine appropriate care, benefits and payments or transfer of services to be released to Sleep well, Inc., Insurance carrier, external review organizations, sleep testing facility, physician or other as required for my continuum of care. Digital Signature *
