Diabetic Supplies Enrollment Form HiddenSigned 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 InformationGot 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 For security purposes may we have your date of birth?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 What is your gender?* Male Female 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.HiddenHidden Field – Phone (Google Sheets) Where should we send your supplies or samples… no PO Boxes please!Contact Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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 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?*DexcomAbbott FreeStyle LibreEversenseOther Medical Insurance InformationSo 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?*MedicareMedicaidPrivateI'm Paying CashDo 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#?* HiddenLast Entered Medicare ID Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Invalid Member ID. Please make sure the patient name, date of birth and Member ID match and are valid.HiddenHidden Approve deny Traditional Nontraditional Invalid Mismatch Internal Error Invalid Medicare ID Format HiddenMismatch Returned Name First Last HiddenMismatch Returned DOB HiddenInternal 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?* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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?* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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?*YesNo 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?* Doctor's InformationBy 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 InformationPlease 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.HiddenSearch Type search manual result confirmed HiddenResults Found Yes No Empty Select Your Doctor Here:Select DoctorDoctor's First Name Doctor's Last Name Office Location City Office Location StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYOffice Location Zip Doctor's Phone Number*Alternate Doctor's Phone NumberThank 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.HiddenNPI Number HiddenNNPES Full Name HiddenNNPES Address Street HiddenNNPES Address City State HiddenNNPES Phone Number HiddenNNPES Fax Number Medication RequestHere 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. 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 Emergency Contact InformationEmergency Contact Name First Last Emergency Contact Phone NumberThat’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!HiddenpVerify Verification Information