Pulse Oximeter Request Form

1. Requestor’s Information
(This person that will be responsible for managing all requests and will be contacted directly) *This question is required.

First Name

Last Name

Title

Practice Name

Street Address

Apt/Suite/Office

City

State

Zip This question requires a valid number format.

Email Address

Phone Number

NPI of Lead Practitioner

2. What is the delivery address? Please note: the delivery must occur in New York City. *This question is required.

Street Address

Apt/Suite/Office

City

State

Zip This question requires a valid number format.

Phone Number

3. Hours for deliveryPlease select days and times you are able to accept a delivery.

Space Cell	Start time	End time
Monday	Monday: Start time	Monday: End time
Tuesday	Tuesday: Start time	Tuesday: End time
Wednesday	Wednesday: Start time	Wednesday: End time
Thursday	Thursday: Start time	Thursday: End time
Friday	Friday: Start time	Friday: End time
Saturday	Saturday: Start time	Saturday: End time
Sunday	Sunday: Start time	Sunday: End time

Please provide tax ID to verify non-profit status:

*This question is required.

5. What percentage of the practice’s patient panel is uninsured or publicly insured?

	Uninsured
	Medicaid
	Medicare
0 out of 100% Total

By submitting this form, you are notifying the New York City Department of Health and Mental Hygiene (the Department) that you are authorized to speak for the organization named above, and that the organization is in need of the supplies you have described as part of its response to the COVID-19 pandemic. The Department will consider these needs in planning the distribution of supplies as part of its ongoing response to the COVID-19 emergency. The Department may share your information with partner organizations that can help procure and/or deliver supplies to your organization.

The Department does not guarantee that all needs submitted through this form will be met.

PLEASE NOTE: The requested items are currently being provided by the City and the requestor will NOT incur any potential costs.

Additional resources:

Pulse Oximeter Distribution Provider Guidance (PDF, November 16)
Patient Fact Sheet: How to Monitor Your Oxygen Level (PDF, November 9)