<p> 129 West Hibiscus Boulevard, Suite A Melbourne, FL 32901 Phone (321) 434-3400 Fax (321) 727-1200 Fax Referral Form</p><p>Patient Information Date: ______</p><p>______First Name MI Last Name ______Address ______City State Zip Code Phone Number ______Height Weight SSN DOB Cell Number</p><p>Payer Information ______Payment due upon delivery Private Pay Health First______Primary Insurance ID# Group# ______Secondary Insurance ID# Group#</p><p>Equipment Ordered ______Diagnosis Length of Need</p><p>□ Oxygen______LMP via______SATS______Hours/Day or______□ Oxygen □ Stationary concentrator □Portable □Conserving device □ CPAP______cmH2O_____with_____without RAMP_____humidification Heated/Passive □ BiPAP_____/_____cmH2O_____humidification Heated/Passive □ BiPAP-ST_____/_____cmH2O_____BMP_____humidification Heated/Passive □ Nebulizer______Supplies______Mask______Medication______□ Wheelchair: _Standard______□ Wheeled Walker______Seat/Brakes______□ Std. Walker______□ Fixed Hospital Bed______□Variable height______□Semi-electric______□ 3-in-1 Commode______□ Cane______□ CPM______Settings______□ Quad Cane______□ TENS Unit □ 2 Lead □ 4 Lead Supplies______□ Other______</p><p>Ordering physician name/signature______Date______</p><p>Ordering physician (Printed name) ______NPI______</p><p>Confidentiality Note: The information contained in this facsimile message may be legally privileged and confidential information intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this telecopy is strictly prohibited. If you have received this telecopy in error, please </p><p>D:\Docs\2017-12-29\05b165100235185e1d40eddb369806c4.doc immediately notify the send above and return the original message to us at the address above by the United States Postal Service. Thank you for your cooperation. </p><p>D:\Docs\2017-12-29\05b165100235185e1d40eddb369806c4.doc</p>