TRS Care: Wigs Through Insurance (NEW)

Just need a few more items.

Please continue filling out the form below, so we can check your eligibility, coverage amount, and provide you with your wig options.
Please fill out this form.
Name*

First NameLast Name
Phone Number*
Date of Birth*

YearMonthDay
Email*
example@example.com

A little bit more.

Since each insurance plan and individual coverage is different, we will use your insurance information to call your insurance provider and ask them coverage questions specific to your policy.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Insurance*
Tricare ID #*
11-digit number DBN on the back of your card or the 9-digit sponsor Social Security Number (SSN)
Member ID #*
We need this to verify your insurance eligibility and coverage amount.
ChampVA Authorization Card*
This is also your sponsor's social security number. We need this to verify your insurance eligibility and coverage amount.
Secondary Insurance (if any)
Your Diagnosis
Example: Breast Cancer, Ovarian Cancer, Lymphedema, etc.
Please enter your diagnosis or procedure code (optional)
Example: C17.0, C56.1, C55, C25.0, C16.0, etc.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
For faster verification, please attach a picture of your insurance card.

Since each insurance plan and individual coverage is different, we use the insurance information you provide to call your insurance provider and ask them coverage questions specific to your policy.
Cancelof

Almost done.

Please specify which products are you looking for and we will check your eligibility and coverage amount for the selected items.
Which products are you looking for?*

Medical WigsMastectomy Care Products
Have you received a wig through your insurance?*
Have you received mastectomy wear through your insurance?*
When is/was the date of your breast surgery?

YearMonthDay
Date
What side was your surgery performed?*
Please select all items you're interested in.
Do you have a cranial prosthesis prescription from your physician?*
Do you have a mastectomy wear prescription from your physician?*
Do you have a prescription from your physician?*
Please attach a copy of your signed prescription.

Please attach a copy of your prescription signed by your physician.
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No worries! We can help you get one.

Please provide your physician's information so we can contact them.
Physician's Name*
Physician's Phone Number*
Please request your doctor to fill out this prescription template for a “cranial prosthesis” aka medical wig and email it back to us at hello@trscare.org or fax it to us at (281) 602-5094.

Download Cranial Prosthesis Prescription Template
Please request your doctor to fill out this prescription template for mastectomy care products and email it back to us at hello@trscare.org or fax it to us at (281) 602-5094.

Download Mastectomy Wear Prescription Template
Please request your doctor to fill out these prescription templates for a cranial prosthesis and mastectomy care products and email them back to us at hello@trscare.org or fax it to us at (281) 602-5094.

Download Cranial Prosthesis Prescription Template

Download Mastectomy Wear Prescription Template

One Last Thing...

Just need your autograph, and you're all set! We'll process your application within 24 - 48 business hours and let you know if we need anything else :)
Have you received a breast pump through your insurance?*
How did you hear about us?*
Which Doctor's Office?
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Can we get your autograph, please?*

Clear
Should be Empty:

Just need a few more items.

Please fill out this form.

A little bit more.

Almost done.

No worries! We can help you get one.

One Last Thing...