Practice Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you plan on servicing out of multiple locations? (ie delivering appliances in different offices) *

Yes

No

Practice Phone *

(###)

###

####

Fax

(###)

###

####

Office Contact Name

First Name

Last Name

Primary Doctor Name *

First Name

Last Name

2nd - Doctor Name (if applicable)

First Name

Last Name

3rd - Doctor Name (if applicable)

First Name

Last Name

Is your practice a Medicare DME supplier for Oral Appliance Therapy? *

YES - I am a Non-Participating Medicare DME Supplier (medicare reimburses our patients directly)

YES - I am a Participating Medicare DME Supplier (medicare reimburses our practice directly)

NO - I am Not a Medicare DME Supplier

Are you a registered Tri-care provider? *

Yes

No