Wound Care Supplies Enrollment Form HiddenSigned Date MM slash DD slash YYYY Questions with (*) are required. Are you or a loved one currently using wound care products? Are you interested in receiving our wound care products from Trust Home Medical, an American owned and operated company?* Yes, I am ready to join Trust Home Medical! I have Wound Care products but I just want a Free Sample. I am looking for guidance on the right products. So let’s find out who’s looking to get the supplies first…are you completing this on behalf of yourself or someone you love?*MyselfLoved one 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?* First Last For security purposes may we have your date of birth?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 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 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Invalid 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 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 Supplies InformationIn 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).Requested SuppliesRef/Product# (if applicable, or n/a)DescriptionQuantity Per Month Click + to add more products to the listConsent 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 don’t have to wash or reuse your products. 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 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. By submitting below you agree that you understand and authorize this service. CLICK AND DRAG TO SIGN BELOW!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.* Click Here to Review Our Authorization of Benefits Form 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 wound care products. Thank you for trusting Trust Home Medical!HiddenpVerify Verification Information