Customer Referral Form

Thank you for choosing Health Aid of Ohio! To start the referral process, please fill out the customer referral form below. For any questions, get in touch with our Customer Service team at (216) 252-3900 or toll-free at (800) 762-5438. 
 

Remote Captcha 8559 Remote Captcha 6502 Remote Captcha 2988

• * - Indicates required fields

• Customer Information

• First Name*
• Last Name*
• Email*
• Address*
• Address Line 2
• City*
• State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Zip*
• Home Phone
• Mobile Phone*
• Date of Birth*

• Equipment

• Equipment

  Ambulatory Aids Breast Pump Compression Stocking/Garments CPAP/BiPAP Machine CPAP/BiPAP Supplies Home Modification Hospital Bed Other

  Other:
• Equipment

  Lift Chair Nebulizer and Supplies Oxygen Scooter Support Surface Vehicle Lift Wheelchair

• Insurance Information

• Insurance Company*
• Insurance ID*
• Doctor's Office Name*
• Doctor's Phone Number*
• Doctor Name*

• Prescription

• Prescription

  I will upload a photo now

  Please attach a file:*

  I will fax a copy to: 216-252-4930 Please contact my doctor for a copy
• Questions / Comments*