Medx.US Affiliate Form:

Affiliate ID(Required)

Click here to receive your Affiliate ID. ID uses the following format: AA-0000

Order Type

New Order

Re-Order

Client Information

Client Name(Required)

First Last

Client Email(Required)

Client Phone(Required)

Client ID

Drop files here or

Accepted file types: jpg, png, heif, heicavif, webp, Max. file size: 10 MB, Max. files: 2.

Front and Back of the ID must be provided.

Date of Birth(Required)

MM slash DD slash YYYY

Point of Contact Information

Point of Contact Name

First Last

Point of Contact Email

Point of Contact Phone

Point of Contact's Relationship to client

Son

Grandson

Daughter

Granddaughter

Aunt

Uncle

Niece

Nephew

Other

Does the point of contact individual have power over attorney for the client?

Yes

Do you want to enter physician information?

Yes

Physician Information

Physician Name(Required)

First Last

Physician Phone(Required)

Physician Address(Required)

City State ZIP Code

Does your client have any Physician's orders?

Yes

Physician's order Information

Physician's order Upload

Drop files here or

Accepted file types: jpg, png, heif, heic, avif, webp, Max. file size: 10 MB, Max. files: 10.

Insurance Information

Insurance Type

Medicare

Medicaid

Private Insurance

Policy #

Group #

Insurance Card Upload

Drop files here or

Accepted file types: jpg, png, heif, heic, avif, webp, Max. file size: 10 MB, Max. files: 2.

Front and Back of the insurance card must be provided.

Does the client have secondary insurance?

Yes

Secondary Insurance Policy #(Required)

Secondary Insurance Group #(Required)

Secondary Insurance Card Upload

Drop files here or

Accepted file types: jpg, png, heif, heic, avif, webp, Max. file size: 10 MB, Max. files: 2.

Front and Back of the insurance card must be provided.

Order Information

Client needs products for the following conditions(Required)

Urological

Incontinence

Enteral Nutrition

Ostomy

Mobility

Diabetes

My client's condition isn't listed.

My client has the following UNLISTED conditions:(Required)

My Client needs the following Mobility products(Required)

Wheelchairs

Walkers

Canes

Bathroom Aids

Hospital Bed

What type of Wheelchair does your client require?(Required)

Standard

Transport Chair

Powered Wheelchair

Heavy Duty

Light Weight

Your client requires a Heavy Duty Wheelchair so we require additional information(Required)

The client weighs more than 250lbs.

The client has severe spasticity

The client's girth requires heavy duty wheelchair.

Check all that apply.

Specify the girth of the client in inches(Required)

Please enter a number from 1 to 80.

We require this information for insurance reporting purposes.

Your client requires a Light Weight Wheelchair. Please confirm client is unable to self-propel in a standard wheelchair.(Required)

My client is unable to self-propel in a standard wheelchair.

Specify the required seat width for client(Required)

12"

14"

16"

18"

20"

22"

24"

26"

28"

We require this information for insurance and product reporting purposes.

Specify the required seat width for client in inches(Required)

Please enter a number from 16 to 24.

We require this information for insurance and product reporting purposes.

My client requires the following additional wheelchair accessories

Anti Tippers

Elevating Leg Rests

General Cushion

Pressure-relief cushion

Required accessory isn't listed

My client needs the following UNLISTED wheelchair accessories:(Required)

My client needs Mobility products that are not listed

Yes

My Client needs the following Walkers products(Required)

Standard Rolling Walker

Heavy Duty Rolling Walker

Rollator with Basket

Jr. Rolling Walker

4 Wheeled Rolling Walker with seat (Rollite)

2 Wheeled Roller Walker with seat (Walklite)

Platform Attachment

Required Walker product not listed.

My client needs the following UNLISTED walker products:(Required)

My Client needs the following Cane products(Required)

Straight Cane

Large Base Quad Cane

Small Base Quad Cane

My Client needs the following Bathroom Aid products(Required)

Bedside Commode (3 in 1)

Shower Chair

Transfer Bench

Safety Grab Bars

Pull Down Shower

Required Bathroom Aid product not listed.

Your client requires a Bedside Commode. Please confirm client is room confined (at night or when caregiver is not available).(Required)

My client is room confined.

My client needs the following UNLISTED bathroom aid products:(Required)

My Client needs the following Hospital Bed products(Required)

Hospital Bed

Trapeze Bar

Patient Lift (Hoyer)

Sliding Board

Your client requires a Hospital Bed. Please confirm client has medical condition which requires positioning of the body in ways not feasible with an ordinary bed.(Required)

My client has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed.

My Client needs the following Ostomy products(Required)

Closed End Bags

Drainable Bags

Urinary Ostomy Bags

Wafers

Stoma Caps

Appliance Cleanser

Deodorizers

Paste

Powder

Tape

Closed End Bags Item #(Required)

Closed End Bags - Quantity per Month(Required)

Please enter a number from 1 to 999.

Drainable Bags Item #(Required)

Drainable Bags - Quantity per Month(Required)

Please enter a number from 1 to 999.

Urinary Ostomy Bags Item #(Required)

Urinary Ostomy Bags - Quantity per Month(Required)

Please enter a number from 1 to 999.

Wafers Item #(Required)

Wafers - Quantity per Month(Required)

Please enter a number from 1 to 999.

Stoma Caps Item #(Required)

Stoma Caps - Quantity per Month(Required)

Please enter a number from 1 to 999.

Appliance Cleanser Item #(Required)

Appliance Cleanser - Quantity per Month(Required)

Please enter a number from 1 to 999.

Deodorizers Item #(Required)

Deodorizers - Quantity per Month(Required)

Please enter a number from 1 to 999.

Paste Item #(Required)

Paste - Quantity per Month(Required)

Please enter a number from 1 to 999.

Powder Item #(Required)

Powder - Quantity per Month(Required)

Please enter a number from 1 to 999.

Tape Item #(Required)

Tape - Quantity per Month(Required)

Please enter a number from 1 to 999.

My client needs Ostomy products that are not listed.

Yes

My client needs the following UNLISTED Ostomy products(Required)

Product Name

Quantity per Month

My client needs the following Enteral Nutrition products(Required)

Feeding Formula

Feeding Bags

Feeding Tubes

Syringes (60cc)

Gauze, each

Gravity Feeding Bags

Check each that apply to your client's nutrition situation(Required)

Sole Source of Nutrition

G or J Tube Placed

Patient Will Be Fed For At Least 3 Months

Feeding Formula Brand(Required)

Cans per Month(Required)

Please enter a number from 1 to 999.

Feeding Bags - Quantity per Month(Required)

Please enter a number from 1 to 999.

Feeding bags - Size(Required)

Feeding Tubes - Quantity per Month(Required)

Please enter a number from 1 to 999.

Feeding Tubes - Size(Required)

Syringes (60cc) - Quantity per Month(Required)

Please enter a number from 1 to 999.

Gauze, each - Quantity per Month(Required)

Please enter a number from 1 to 999.

Gravity Feeding Bags - Quantity per Month(Required)

Please enter a number from 1 to 999.

My client needs the following Incontinence products(Required)

Disposable Briefs/Diapers

Chux/Underpads

Liners/Pads/Shields

Undergarments

Disposable Briefs/Diapers - Quantity per Month(Required)

Please enter a number from 1 to 999.

Chux/Underpads - Quantity per Month(Required)

Please enter a number from 1 to 999.

Liners/Pads/Shields - Quantity per Month(Required)

Please enter a number from 1 to 999.

Undergarmets - Quantity per Month(Required)

Please enter a number from 1 to 999.

My client needs Incontinence products that are not listed.

Yes

My client needs the following UNLISTED Incontinence products(Required)

Product Name

Quantity per Month

My client needs the following Urological products(Required)

Insertion Trays

Irrigation Trays

Leg Bag, Disposable

Drainage Bags

Adhesive Remover

Lubricant

Foley Catheters

Intermittent Catheters

External Catheters

Sex for client with urological condition(Required)

Male

Female

Insertion Trays - Quantity per Month(Required)

Please enter a number from 1 to 999.

Irrigation Trays - Quantity per Month(Required)

Please enter a number from 1 to 999.

Leg Bag, Disposable - Quantity per Month(Required)

Please enter a number from 1 to 999.

Leg Bag, Disposable - Quantity per Month(Required)

Please enter a number from 1 to 999.

Drainage Bags - Quantity per Month(Required)

Please enter a number from 1 to 999.

Adhesive Remover - Quantity per Month(Required)

Please enter a number from 1 to 999.

Lubricant - Quantity per Month(Required)

Please enter a number from 1 to 999.

Foley Catheter - Quantity per Month(Required)

Please enter a number from 1 to 2.

Foley Catheter - Size(Required)

Foley Catheter - CC(Required)

Intermittent Catheter - Quantity per Month(Required)

Please enter a number from 1 to 30.

Intermittent Catheter - Size(Required)

External Catheter - Quantity per Month(Required)

Please enter a number from 1 to 30.

External Catheter - Size(Required)

Small

Medium

Large

Extra Large

Additional comments that the DME provider should know

Please upload any discharge notes provided by physician

Drop files here or

Accepted file types: jpg, png, heif, heic, avif, webp, Max. file size: 10 MB, Max. files: 10.

Client's Mailing Address

Street Address Address Line 2 City State ZIP Code

Client's Billing Address

Street Address Address Line 2 City State ZIP Code

*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. 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.

Authorization of benefits signed by Power of Attorney(Required)

Authorization of benefits signed by Client(Required)

This field is for validation purposes and should be left unchanged.

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