Program Enrollment

The Physician Program Enrollment Form is used solely for the purpose of obtaining your office contact information. There is never a contract that obligates you to work with SMG. We hope to earn that loyalty by providing consistently excellent service.

Please fill out the form below and click submit or, if you prefer, you may download and print the form by clicking here. Completed forms may be faxed to us at 800-717-2573.

If you wish to provide us with your contact information at a later date, you can feel free to get started right away with patient DME requests by clicking here.

Contact Us

SMG Mediquip, LLC
P.O. Box 736
Bethpage, NY 11714
516.586.4934 (phone)
800.717.2573 (fax)
800.211.0404 (fax)