Diabetics Enrollment | Trust Home Medical

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Diabetic Supplies Enrollment Form

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Signed Date
MM slash DD slash YYYY
Questions with (*) are required.
Are you completing this form on behalf of yourself or your loved one?*
- Myself
- Loved One
What is your relationship with the patient?*
- Spouse
- Sibling
- Friend
May we have your name please? (Loved One)*
First Last
Patient Information
Got it, the rest of the questions please answer as if you are the patient, but you will put in your information in the Emergency Contact section at the end.
What is your name? (The Patient/Myself)*
First Last

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For security purposes may we have your date of birth?*

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What is your gender?*
- Male
- Female

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What is the best way to contact you?*
- Email
- Phone
- Text
Can you please provide your email address?*
What is the best phone number we can use to contact you?*
Do you mind also providing your phone number?*
By submitting this information, you authorize Trust Home Medical to contact you regarding your insurance, supplies, or provider information. Trust Home Medical promises to never give out your number or use it for any marketing related reasons.
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Where should we send your supplies or samples… no PO Boxes please!
Contact Address*
Street Address Address Line 2 City State ZIP Code

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Great! Now let's get some information on your diabetic history and diagnosis information.
Providing diabetic history will help us determine the best advice to give alongside your supplies. We sincerely care about you.
Do you have Type 1 or Type 2 diabetes?*
- Type 1
- Type 2
- I’m not sure/Other
Are you currently insulin dependent?*
- Yes
- No
Have you been insulin dependent starting from childhood or adulthood?*
- Childhood
- Adulthood
Have you experienced Elevated Glucose levels or low A1C levels?*
- Yes
- No
Have you in the past or are currently using MedForman or Glucose Controlling Medications (GCM)?*
- Yes
- No

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Are you currently insulin dependent?*
- Yes
- No
Medicare guidelines require patients to check their blood glucose levels at least 3 times per day.
Are you currently using any Continuous Glucose Monitors (CGMs) or PUMPs?*
- Yes
- No
Medicare guidelines require patients to check their blood glucose levels at least once per day.
Are you currently using any Continuous Glucose Monitors (CGMs)?*
- Yes
- No
What brand of CGM and/or PUMP do you currently use?*

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Medical Insurance Information
So we can make sure the supplies are covered by your insurance at little or no cost to you, can you give us your insurance information?
What is your Primary Medical Insurance Provider?*
Do you have Traditional Medicare or Medicare Advantage?*
- Traditional Medicare
- Medicare Advantage / Nontraditional
What is the name of your Medicare Insurance Carrier?*
What is your Medicare Member ID#?*
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Last Entered Medicare ID
Name*
First Last
Date of Birth*
Invalid Member ID. Please make sure the patient name, date of birth and Member ID match and are valid.
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- Traditional
- Nontraditional
- Invalid
- Mismatch
- Internal Error
- Invalid Medicare ID Format
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Mismatch Returned Name
First Last
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Mismatch Returned DOB
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Internal Error Message
Is your Private Insurance managing a Medicare or Medicaid plan?*
- Yes, it is managing my Medicare plan
- Yes, it is managing my Medicaid plan
- No
What state is your Medicaid insurance registered for?*
State
What is your Medicaid Member ID#?*

This is on your Medicaid card right beneath your name.
Which Private Carrier do you have?*
- Blue Cross Blue Shield
- United Health
- Cigna
Is this an HMO, PPO, or other type of insurance plan?*
- HMO
- PPO
- Other/I don’t know
What is your insurance Member ID#?*
May you please provide the Toll-Free number for your Primary Carrier? This is usually a 1-800 number found on the front or back of the card.
Do you also have Medicare Supplemental, Medicaid, or a Secondary Private Insurance?*
- Medicare Supplemental
- Secondary Private Insurance
- Medicaid
- Neither, I only have my Primary Insurance
What state is your Medicaid insurance registered for?*
State
What is your Medicaid Member ID#?*

This is on your Medicaid card right beneath your name.
What is the name of your Secondary Insurance Carrier?*
What is the Member ID for your Secondary Carrier?*

It may be listed as a Subscriber ID or Member ID. It is usually the long number on your card.
May you please provide the Toll-Free number for your Secondary Carrier? This is usually a 1-800 number found on the front or back of the card.
Have you received glucose meter covered by your insurance within the last 3 years?*
Medicare will cover your supplies. However, Medicare is limited to reimbursement, so to ensure you have little to no pocket costs we are going to send you a brand new glucose monitor for FREE
Medicare will pay for a new meter every 3 years. Since you have not received one within the past 3 years, we will supply you with a new meter with your first order that will be billed to your insurance.
Your first order will get you a brand new meter.
How many times do you check your blood sugar per day/ how often does your physician require you to check your blood sugar per day?*
Have you been enrolled in Home Health or a skilled nursing facility within the past year?*
- Yes
- No
Are you currently still enrolled?*
- Yes
- No
What was the date of discharge?*

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Doctor's Information
By providing your doctor’s information we can obtain approval to get your supplies delivered to you.
Please search for your Doctor using the fields below.
Please select your Doctor from the list and click This Is My Doctor below. If your Doctor is not listed, Search Again, or click Cannot Find My Doctor.
No Results Found? Click Search Again to keep searching, or click Cannot Find My Doctor to Enter Their Information
Please enter as much of your Doctor’s information below. If you do not know your Doctor’s information please provide the best phone number to reach them in the Doctor’s Phone number box below. When finished click Next at the bottom.
We were not able to find matching results from your search.

Please enter as much of your Doctor’s information below. If you do not know your Doctor’s information please provide the best phone number to reach them in the Doctor’s Phone number box below. When finished click Next at the bottom.
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Search Type
- search
- manual
- result
- confirmed
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Results Found
- Yes
- No
- Empty
Select Your Doctor Here:
Doctor's First Name
Doctor's Last Name
Office Location City
Office Location State
Office Location Zip
Doctor's Phone Number*
Alternate Doctor's Phone Number
Thank you. Please enter your Doctor’s Phone Number found on your most recent medication if it is not the same as the one listed below and please click next.
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NPI Number
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NNPES Full Name
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NNPES Address Street
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NNPES Address City State
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NNPES Phone Number
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NNPES Fax Number

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Medication Request
Here is a list of the supplies we are going to request approval from your Doctor for. You may not need these every shipment, however, with your Doctor’s approval we can ship you the following supplies upon request.
Please select any of the supplies below that you would like to come with this shipment. These supplies will come with your new Glucose Monitor, Testing Strips, and Lancets.
- Lancets
- Lancet Device
Consent to contact Doctor*
By checking this box I agree to allow Trust Home Medical to contact my Doctor requesting written approval for the above-listed products.

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Ok, we are almost done! We will send a complete 90 day order. Re-ordering is easy, we will call you before you run out so you are not without your diabetic supplies. We take care of billing the insurance and requesting medical records from your doctor. All of this is included FREE with your membership. You understand co-pays and deductibles apply. We are sure you will be completely satisfied, but if you want to return the supplies for any reason, just call us within 30 days and we will pick up the unused supplies for FREE. Shipping is always FREE both ways. Please review the agreement then sign below and you are all set!
I request payment of authorized Medicare and/or insurance benefits to me or on my behalf for any services furnished by Trust Home Medical, LLC. I authorize any holder of medical information about me to release to Medicare, its agents, Insurance and Trust Home Medical any information needed to determine/bill these benefits per Trust Home Medical's authorization of benefits. I authorize Trust Home Medical, LLC. to contact me for any reason. I or my caregiver can properly use the supplies requested. Patient responsible for payments not paid by Medicare and/or Insurance including deductibles and co-insurance. Please ship and bill Medicare and/or my insurance for my complete order I am requesting.*
Trust Home Medical LLC. PO Box 33 . Valrico, FL 33595 1-800-976-3826 Fax 1-813-762-0076

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Emergency Contact Information
Emergency Contact Name
First Last
Emergency Contact Phone Number
That’s it! Here is what happens now. We’ll confirm with your doctor and insurance before sending you your complete 90-day order.
Re-ordering is easy, we will call you before you run out. You understand we will be billing your insurance on your behalf and you will be responsible for any co-pays and deductibles that may apply. We are sure you will be completely satisfied, but if you want to return supplies for any reason, please call us within 30 days and we’ll pick them up.
It’s that Easy! I know you are going to like this new service and these new diabetic products. Thank you for trusting Trust Home Medical!
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