Change Provider Notice

Care Airways Corporation
1095 Broken Sound Parkway NW Suite 101
Boca Raton, FL 33487

Phone : 855.713.1012
Fax : 561.634.3424

CHANGE PROVIDER NOTICE

Patient Name :

Patient Email :

Patient DOB :

Date :

Patient Date of Service:

Oxygen Provider:

Phone:

Fax:

Please be notified, I have exercised my rights and have chosen to change oxygen providers, effective immediately. My new oxygen provider is Care Airways Corp, who have already installed new oxygen equipment in my home and have instructed me to it’s proper use.

Per Medicare Supplier Standards, you are notified to pick up your rental equipment immediately. Your rental equipment is no longer in use. Should there be any delay in the equipment pickup; you are notified and instructed on this day to cease billing immediately. All future claims from this date forward on my Date of Service will be submitted by my new provider Care Airways Corp. You are further instructed to immediately release ALL of my oxygen related documentation on file and fax to Care Airways Corp. Fax number: 561.634.3424

Thank you for your cooperation in this matter.

Your e-Signature

Date: