Medical Information Form

TLG FORM
CENTER AGENT LAST NAME
CENTERAGENT LAST NAME
Customer's
First NameLast Name
E-mail
Birth Date
MonthDayYear
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Diabetic Medicare Information
Are you diabetic?
What is your primary insurance?
How many times per day do you test?
Medicare Claim Number
Gender
Doctor's
First NameLast Name
Doctor's State
Doctor's NPI
Doctor's Phone
Doctor's Fax
Doctor's Address
Doctor's City
Doctor's Zip
Patient Comment
Diabetic Private Insurance
Have you been diagnosed with diabetes?
What type of insurance do you have?
Do you also have Medicare?
Are you open to a changing suppliers if they could provide a better service to you?
What is your Primary Insurance Carrier?
Are you under 65?
What is the name/brand of your current testing meter?
What company do you currently get your supplies from?
How many times do you test per day ?
Are you currently getting your supplies via mail order OR 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?
Mobility Information
Mobility Lead
Do you currently use a cane or a walker or have difficulty getting around?
Have you been prescribed a motorized power chair (prescribed by your doctor) within the last 5 years?
What is your primary insurance?
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?
CPAP
Do you currently suffer from Sleep Apnea or use a CPAP or BIPAP machine?
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?
Have you had your PAP machine longer than 5 years?
What is your current insurance?
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?
Agent Verification
Have you verified that the patient currently use's at least one of the products above?
I have verified that the patients insurance matches the insurance listed above.
I have verified that the patient is willing to discuss changing their supplier.
Should be Empty:

TLG FORM

Diabetic Medicare Information

Diabetic Private Insurance

Mobility Information

CPAP

Agent Verification