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  • 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.

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  • 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!

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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?
  • Invalid Medicare ID. Please make sure the patient name, date of birth and Medicare ID match and are valid.
  • This is on your Medicaid card right beneath your name.
  • It may be listed as a Subscriber ID or Member ID. It is usually the long number on your card.
  • This is usually a 1-800 number found on the front or back of the card.
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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 Next 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 all of your Doctor’s Information including their phone number found on your most recent medication. When finished click Next at the bottom. You may also Search Again if you’d like.
  • 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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  • Supplies Information

  • In order to find your supplies please list any of your current supplies and any requested supplies below. Please try to include as much information as possible for each (product/reference #, description, amount per month).

  • Ref/Product# (if applicable, or n/a)DescriptionQuantity Per Month 
    Click + to add more products to the list
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  • Emergency Contact Information

  • 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 wound care products. Thank you for trusting Trust Home Medical!
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