New Patients - QualityDME

New Patients

In order to become a patient, please fill out the information below and upload the necessary documentation. A Quality DME team member will contact you within the next business day. We will initiate contact with your insurance company to verify eligibility and benefits, and start any necessary authorizations. Once the insurance authorization is complete, we will contact you to schedule your equipment to be delivered.

Please be sure to review our insurance acceptance list prior to completing this form. View Insurance List

1General Info

2Insurance

3Documentation

General Info
How did you hear about Quality DME?*
First Name*
Last Name*
Primary Phone Number*
Date of Birth*
Month
Day
Year
Email Address*
Home Address*
Street Address Address Line 2 City State ZIP Code