Device Order Form – Example


An example form from the device vendor to order and activate monitoring devices for patients participating in the telehealth program. The form includes pertinent activation information including, member information, device type and peripheral devices, device serial number, device language and shipment date.


Program designers and managers, technology managers, device vendors, and field personnel.

Helpful Tips

  • For faster device activation, fax this form to the vendor.
  • Determine whether patients have a landline or cellular form and select the device based on patients’ telephonic connectivity and preference.

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