PAP Supplies Request - Hurst
Hurst PAP Supplies Request
You will be contacted at the phone
number/email below so we may get details needed to complete your
request. You'll then be advised when your requested supplies are
being mailed or are ready to pick up.
If you have questions about this form
or about your PAP Supplies, please call the office at (817)
393-8772, or email
By submitting this form, you are
requesting that we issue replacement PAP supplies to you. If you do not
presently get your PAP supplies from us, please enter the name of your
current DME company so we may contact them to obtain information about your
Item (hover your mouse
cursor over the
to see a sample item)
Enter any notes you might have
for our staff:
Choose how you would like to get your supplies:
Note: This is a non-secure communication.
You must indicate your acceptance of the use of this form by checking
the box below.
hereby acknowledge that this form is unencrypted and not a secure means
of electronic communication with my healthcare provider or facility. I
agree to allow my healthcare provider or facility staff to reply to the
email address indicated on this form, and to forward or share the
information contained in this form, including any Personal Health
Information (PHI), with other health professionals or associated staff
using non-secure electronic communication methods such as email.