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Diabetic Medicare Information
Are you diabetic?
Please Select
- Select -
Yes
No
What is your primary insurance?
Please Select
- Select -
Medicare
Private Insurance
How many times per day do you test?
Please Select
1
2
3
4
5
6
7
8
9
10
Medicare Claim Number
Gender
Please Select
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Male
Female
Doctor's
First Name
Last Name
Doctor's State
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Doctor's NPI
Doctor's Phone
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Patient Comment
Diabetic Private Insurance
Have you been diagnosed with diabetes?
Please Select
- Select -
Yes
No
What type of insurance do you have?
Please Select
- Select -
Medicare
Private Insurance
Do you also have Medicare?
Please Select
- Select -
Yes
No
Are you open to a changing suppliers if they could provide a better service to you?
Please Select
- Select -
Yes
No
What is your Primary Insurance Carrier?
Please Select
4 Most Health Network
Advantra
Aetna
Allegiance Provider Direct LLC
Alliance Health Plan of LancasterEHP
Alliance Regional Health Network
Alliant Health Plan
American PPO Inc
American Progressive
American Republic Insurance
Americas PPO
Ancillary Care Services
Anthem
Arkansas Managed Care Organization (AMCO)
ASR (Physicianscare Health Plans)
AWAC LLC
Beech Street
Best Care
Blue Cross Blue Shield
Blue Ridge Health Network
BlueChoice HealthPlan South Carolina
Boon Chapman
Bravo
Care Improvement Plus
Carelink
CCO Inc
Center Care
Century Health Solutions
CHN Solutions
Cigna
Clear One Health Plans
Cofinity (PPOM)
Community First
Community HealthPartners
Coventry Health CareCrescent PPO
Devon Health Services Inc
DirectNet LLC
Discount Choice Network
El Paso First Health Plan
ELMCO LLC
Employers Community Network
Evercare
Evercare of Texas
Evolution HealthCare System
First Choice Health Network
First Choice of the MidWest
First Health Services
FirstCarolinaCare Insurance Company
Fiserv Health
Florida Health Choice
Florida PPO
Focus HealthCare Management
FrontPath Health Coalition
Galaxy Health Network
Gateway Health Alliance
Gilsbar 360 Alliance PPO
Guided2Health
Hawaii Medical Assurance Association (HMAA)
Health InfoNet
Health Management Network
Health One Alliance
Health Partners of Kansas
Health Payors Organization Ltd
Health Plus of Louisiana Inc
HealthChoice Oklahoma
HealthLink
HealthNow NY
HealthPlus of MI
HealthScope Benefits
HealthSmart Preferred Care
Healthspring
Highmark
Hines & Associates
Horizon
Horizons
Humana
Independent Medical Systems
Indiana Health Network
InforMed LLC
Integrated Health Plan
Intel Health
InterGroup Services Corporation
Interplan Health Group
InterWest Health
Island Group
Keystone
MagnaCare
Managed Healthcare Northwest
Martins Point Health Care
MDI Healthcare Solutions
Medcost
Mercy Health Plans
MeritainNorth American Preferred
Mississippi Physicians Care Network
Multiplan
Municipal Health Benefit Fund
National Health Plan Network
NHBC National Health Benefits
North Georgia Health Services
Nova
NPPN (National Preferred Provider Network)
ODS Health Plans Inc
Pacific Care
Pacific Health Alliance
Permian Basin Healthcare Network
PHCS Private Health Care Systems Inc
Piedmont
Pima Health Systems
PlanCare America
Pomco
Preferred Benefits Administrators
Preferred CommunityChoice PPO
Preferred Health Plan
Preferred Network Access
Premier Care
Prime Health Services Inc
PrimeNet Inc
Qualchoice of AR
Quality Health Plans Inc
RMSCO
San Antonio Employee Health Alliance
Scan Village Health
Secure Horizons
Select Net Plus
Sterling Life Ins Co
SuperMed Medical Mutual of OH
Texas True Choice
The Emerald Health Network
Three Rivers Provider Network
TLC Advantage
Tricare
Unicare
United
USA Managed Care Organization
Virginia Health Network
Viva Health
Wausau
Wellpoint
Windsor RX
WNC Health Coalition
WPS Health
Are you under 65?
Please Select
- Select -
Yes
No
What is the name/brand of your current testing meter?
What company do you currently get your supplies from?
Please Select
Am Med Direct
Carefree Health
DEGC Enterprises
Doctor Diabetic
Liberty
Lincare
Med-Care Diabetic
MedEnvios
Neighborhood Diabetes
Other
Rx Solutions
Simplex
Support Plus
United States Pharmceutical
US Med
How many times do you test per day ?
Please Select
- Select -
1
2
3
4
4+
Are you currently getting your supplies via mail order OR pharmacy?
Please Select
- Select -
Mail Order
Pharmacy
What is your favorite color?
I just want to confirm that you are interested in having a qualified Specialist contact you about receiving your supplies at home?
Please Select
- Select -
Yes
No
Mobility Information
Mobility Lead
Please Select
- Select -
Yes
No
Do you currently use a cane or a walker or have difficulty getting around?
Please Select
- Select -
Yes
No
Have you been prescribed a motorized power chair (prescribed by your doctor) within the last 5 years?
Please Select
- Select -
Yes
No
What is your primary insurance?
Please Select
- Select -
4 Most Health Network
AARP
Advantra
Aetna
Allegiance Provider Direct LLC
Alliance Health Plan of LancasterEHP
Alliance Regional Health Network
Alliant Health Plan
American PPO Inc
American Progressive
American Republic Insurance
Americas PPO
AMERIGROUP
AMERIGROUP-SECONDARY
Amrihealth
Ancillary Care Services
Anthem
Arkansas Managed Care Organization (AMCO)
ASR (Physicianscare Health Plans)
AWAC LLC
Beech Street
Best Care
Blue Cross Blue Shield
Blue Ridge Health Network
BlueChoice HealthPlan South Carolina
Boon Chapman
Bravo
Care Improvement Plus
Carelink
CCO Inc
Center Care
Century Health Solutions
CHN Solutions
Cigna
Clear One Health Plans
Cofinity (PPOM)
Community First
Community HealthPartners
Coventry Health CareCrescent PPO
Devon Health Services Inc
DirectNet LLC
Discount Choice Network
El Paso First Health Plan
ELMCO LLC
Employers Community Network
Evercare
Evercare of Texas
Evolution HealthCare System
FIRST CHOICE BY SELECT HEALTH OF SC
First Choice Health Network
First Choice of the MidWest
First Health Services
FirstCarolinaCare Insurance Company
Fiserv Health
Florida Health Choice
Florida PPO
Focus HealthCare Management
FrontPath Health Coalition
Galaxy Health Network
Gateway Health Alliance
Gilsbar 360 Alliance PPO
Guided2Health
Hawaii Medical Assurance Association (HMAA)
Health InfoNet
Health Management Network
Health One Alliance
Health Partners of Kansas
Health Payors Organization Ltd
Health Plus of Louisiana Inc
HealthChoice Oklahoma
HealthLink
HealthNow NY
HealthPlus of MI
HealthScope Benefits
HealthSmart Preferred Care
Healthspring
Highmark
Hines & Associates
Horizon
Horizons
Humana
HUMANA GOLD PLUS
Independent Medical Systems
Indiana Health Network
InforMed LLC
Integrated Health Plan
Intel Health
InterGroup Services Corporation
Interplan Health Group
InterWest Health
Island Group
Keystone
MagnaCare
Managed Healthcare Northwest
Martins Point Health Care
MDI Healthcare Solutions
Medcost
Medicaid
Medicare
Mercy Health Plans
MeritainNorth American Preferred
Mississippi Physicians Care Network
Multiplan
Municipal Health Benefit Fund
National Health Plan Network
NHBC National Health Benefits
North Georgia Health Services
Nova
NPPN (National Preferred Provider Network)
ODS Health Plans Inc
Pacific Care
Pacific Health Alliance
Permian Basin Healthcare Network
PHCS Private Health Care Systems Inc
Piedmont
Pima Health Systems
PlanCare America
Pomco
Preferred Benefits Administrators
Preferred CommunityChoice PPO
Preferred Health Plan
Preferred Network Access
Premier Care
Prime Health Services Inc
PrimeNet Inc
Qualchoice of AR
Quality Health Plans Inc
RMSCO
San Antonio Employee Health Alliance
Scan Village Health
Secure Horizons
SELECT HEALTH OF SOUTH CAROLINA
Select Net Plus
Sterling Life Ins Co
SuperMed Medical Mutual of OH
Texas True Choice
The Emerald Health Network
Three Rivers Provider Network
TLC Advantage
Tricare
Unicare
United
USA Managed Care Organization
Virginia Health Network
Viva Health
Wausau
Wellcare
Wellpoint
WINDSOR EXTRA
Windsor RX
WINDSOR STERLING
WNC Health Coalition
WPS Health
I'd like to have a mobility power chair adviser give you a call to discuss how you can receive a power chair at little or no cost to you. Would that be okay?
Please Select
- Select -
Yes
No
CPAP
Do you currently suffer from Sleep Apnea or use a CPAP or BIPAP machine?
*
Please Select
- Select -
Yes
No
We’d like to get you qualified for a new, more effective model, which will be at no cost to you if you qualify. I just need to confirm a little information. Ok?
Please Select
- Select -
Ok
Not Ok
Have you had your PAP machine longer than 5 years?
*
Please Select
- Select -
Yes
No
What is your current insurance?
*
Please Select
- Select -
4 Most Health Network
AARPAARP
Advantra
Aetna
Allegiance Provider Direct LLC
Alliance Health Plan of LancasterEHP
Alliance Regional Health Network
Alliant Health Plan
American PPO Inc
American Progressive
American Republic Insurance
Americas PPO
AMERIGROUP
AMERIGROUP-SECONDARY
Amrihealth
Ancillary Care Services
Anthem
Arkansas Managed Care Organization (AMCO)
ASR (Physicianscare Health Plans)
AWAC LLC
Beech Street
Best Care
Blue Cross Blue Shield
Blue Ridge Health Network
BlueChoice HealthPlan South Carolina
Boon Chapman
Bravo
Care Improvement Plus
Carelink
CCO Inc
Center Care
Century Health Solutions
CHN Solutions
Cigna
Clear One Health Plans
Cofinity (PPOM)
Community First
Community HealthPartners
Coventry Health CareCrescent PPO
Devon Health Services Inc
DirectNet LLC
Discount Choice Network
El Paso First Health Plan
ELMCO LLC
Employers Community Network
Evercare
Evercare of Texas
Evolution HealthCare System
FIRST CHOICE BY SELECT HEALTH OF SC
First Choice Health Network
First Choice of the MidWest
First Health Services
FirstCarolinaCare Insurance Company
Fiserv Health
Florida Health Choice
Florida PPO
Focus HealthCare Management
FrontPath Health Coalition
Galaxy Health Network
Gateway Health Alliance
Gilsbar 360 Alliance PPO
Guided2Health
Hawaii Medical Assurance Association (HMAA)
Health InfoNet
Health Management Network
Health One Alliance
Health Partners of Kansas
Health Payors Organization Ltd
Health Plus of Louisiana Inc
HealthChoice Oklahoma
HealthLink
HealthNow NY
HealthPlus of MI
HealthScope Benefits
HealthSmart Preferred Care
Healthspring
Highmark
Hines & Associates
Horizon
Horizons
Humana
HUMANA GOLD PLUS
Independent Medical Systems
Indiana Health Network
InforMed LLC
Integrated Health Plan
Intel Health
InterGroup Services Corporation
Interplan Health Group
InterWest Health
Island Group
Keystone
MagnaCare
Managed Healthcare Northwest
Martins Point Health Care
MDI Healthcare Solutions
Medcost
Medicaid
Medicare
Mercy Health Plans
MeritainNorth American Preferred
Mississippi Physicians Care Networkrk
Multiplan
Municipal Health Benefit Fund
National Health Plan Network
NHBC National Health Benefits
North Georgia Health Services
Nova
NPPN (National Preferred Provider Network)
ODS Health Plans Inc
Pacific Care
Pacific Health Alliance
Permian Basin Healthcare Network
PHCS Private Health Care Systems Inc
Piedmont
Pima Health Systems
PlanCare America
Pomco
Preferred Benefits Administrators
Preferred CommunityChoice PPO
Preferred Health Plan
Preferred Network Access
Premier Care
Prime Health Services Inc
PrimeNet Inc
Qualchoice of AR
Quality Health Plans Inc
RMSCO
San Antonio Employee Health Alliance
Scan Village Health
Secure Horizons
SELECT HEALTH OF SOUTH CAROLINA
Select Net Plus
Sterling Life Ins Co
SuperMed Medical Mutual of OH
Texas True Choice
The Emerald Health Network
Three Rivers Provider Network
TLC Advantage
Tricare
Unicare
United
USA Managed Care Organization
Virginia Health Network
Viva Health
Wausau
Wellcare
Wellpoint
WINDSOR EXTRA
Windsor RX
WINDSOR STERLING
WNC Health Coalition
WPS Health
I would like to have a CPAP specialist give you a call to discuss how you can receive a CPAP machine at little or no cost to you. May I do that?
*
Please Select
- Select -
Yes
No
Agent Verification
Have you verified that the patient currently use's at least one of the products above?
*
Please Select
- Select -
Yes, I have.
No, I have not.
I have verified that the patients insurance matches the insurance listed above.
*
Please Select
- Select -
Yes, I have.
No, I have not.
I have verified that the patient is willing to discuss changing their supplier.
*
Please Select
- Select -
Yes, I have.
No, I have not.
Submit
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