Request Callback

*I consent to disclose personally identifiable health information to New England Medical Supply, a durable medical equipment provider for the purpose of receiving treatment. If I choose to limit the information released, I understand it may be necessary for my health care provider to inform the requester that portions of the record have been withheld. This authorization shall remain valid unless revoked and will expire 1 year after signing. This consent is subject to written revocation by the undersigned at any time except to the extent that action has already been taken. I understand that signing this authorization is voluntary and will not condition my treatment, payment, enrollment or eligibility for benefits.