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Patient Services Form

To better serve our patients, Atos is implementing some exciting upgrades to our system that will help streamline the ordering process. Atos Medical recently sent you a Patient Services Book that contains our Patient Service Agreement (PSA) and Notice of Privacy Practices (HIPAA). It is important that you review the updated information and complete/sign the Patient Services Form by September 15, 2019.

The Patient Services Form will become mandatory for placing orders beginning October 1, 2019. Without the form, Atos will be unable to ship product, therefore, we need your cooperation with completing and returning this form promptly.

If you no longer have a copy of the original Patient Services Book and Patient Services Form, you can download them below.

How can you return this document?

  • By mail: Atos Medical Inc, Attn: Patient Services, 2801 South Moorland Road, New Berlin, WI 53151
  • By fax: 844.389.4918
  • Electronically: If you prefer to complete this form electronically, please contact us to request it to be sent to your email address through a secure document signing system

Please review, sign, date and return the Patient Services Form by September 15, 2019.

MC2346 Patient Services Form
  • By signing, I acknowledge that I have received a copy of the above Patient Services Book which contains the Patient Bill of Rights and Responsibilities, Patient Service Agreement, Notice of Privacy Practices (HIPAA), Ordering Laryngectomy Supplies and Understanding Your Benefits.
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MC2345 Patient Services Book
  • Important Patient and Privacy Information
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