Equipment Return Request

Please complete the form below to submit your request.

Rotech will contact you within two business days to arrange the return of your equipment.

If you need to return CPAP supplies (e.g., tubing, headgear, mask, etc.) to Sleep Central,
please complete the CPAP Supply Return Authorization Request.

If you’d like to arrange the return of your Negative Pressure Wound Therapy (NPWT) pump, please submit the NPWT Pickup Request.

Patient's Name(Required)

First Last

Patient ID

Patient's Date of Birth(Required)

Patient's Address

Street Address City State ZIP Code

Phone

Confirm Email

Preferred Contact Method

Your Relationship to Patient

e.g., self, spouse, child, etc.

Preferred Phone Number

Additional comments

Please do not enter medical details in this field.

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Phone

This field is for validation purposes and should be left unchanged.

EMAIL PRIVACY WARNING: Communications via email over the internet in general, and via unencrypted email in particular, are not secure and there is a possibility that information included in an email can be misdirected or intercepted and read by other parties besides the person to whom it is addressed. You should not use email for emergencies or other time-sensitive matters. By submitting information through our request form, you are consenting to receive communication from Rotech Healthcare Inc. (or any of its subsidiaries) via unencrypted email.

Equipment Return Request

Equipment Return Request

Equipment Return Request

Equipment Return Request

Please complete the form below to submit your request.

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