For Medical Providers

Refer a Patient / Submit an Order

Send us the details and we'll follow up to confirm the order. Prescriptions can also be faxed to 866-217-2357 or emailed to info@promeddmeusa.com.

Include the equipment ordered and any claim or payer information in the message field. Please avoid sensitive clinical details in this form.

Practice / organization name

Your name *

NPI (optional)

Phone

Email *

State

Equipment needed

Order details (patient contact, equipment, claim type)

Please do not include sensitive medical details. We respond by phone or email within one business day.