Patient Portal Account Deletion Request

Complete the form below to submit your request.

Rotech’s support team will contact you within two business days to confirm your portal account deletion.
Please note: submitting this form will only delete your Patient Portal Account; it does not remove you from our records as a Rotech patient.

"*" indicates required fields

Name*

First Last

Date of Birth*

Patient ID Number

Email*

Enter Email Confirm Email

Patient Portal Username

Phone

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

EMAIL PRIVACY WARNING: Communications via email over the internet in general, and via unencrypted email in particular, are not secure and there is a possibility that information included in an email can be misdirected or intercepted and read by other parties besides the person to whom it is addressed. You should not use email for emergencies or other time-sensitive matters. By submitting information through our request form, you are consenting to receive communication from Rotech Healthcare Inc. (or any of its subsidiaries) via unencrypted email.

Patient Portal Account Deletion Request

Patient Portal Account Deletion Request

Patient Portal Account Deletion Request

Patient Portal Account Deletion Request

Complete the form below to submit your request.

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