Patient Enrollment - Specialty Medical Equipment

Patient Enrollment

Step 1 of 7

Info

Address

Service

Provider

Insurance

Details

Verify

Step 1 of 7

Personal Information

Let's start with some basic details about you.

Please fill in all required fields.

First Name *

Last Name *

Date of Birth *

Gender *

Primary Phone *

Cell Phone Optional — for text message reminders

Email Address *

Last 4 of SSN * Required for insurance billing verification

Language Preference

Step 2 of 7

Shipping Address

Where should we deliver your supplies?

Please fill in all required fields.

Street Address *

Apt / Suite / Unit

City *

State *

ZIP Code *

Step 3 of 7

Select Your Supplies

Choose the type of supplies you need. You may select one or both.

Please select at least one supply type to continue.

CPAP Supplies

Masks, tubing, filters, and machines

Full face & nasal masks

CPAP tubing & connectors

Filters & chin straps

CPAP & BiPAP machines

CGM / Diabetic Testing

Continuous glucose monitors, test strips, lancets, and meters

Continuous glucose monitors

Test strips & lancets

Blood glucose meters

Insulin pump supplies

Tap a card to select · You can choose both if applicable

Step 4 of 7

Prescriber Information

We need your doctor's information to verify your prescription.

Please complete all required prescriber fields.

Doctor First Name *

Doctor Last Name *

NPI Number *

Valid NPI format

NPI must be exactly 10 digits

Doctor Address *

Address Line 2

City *

State *

ZIP *

Doctor Phone *

Doctor Fax

Step 5 of 7

Insurance Details

We'll verify your coverage before confirming your enrollment.

Please complete all required fields.

Primary Insurance

Insurance Plan Name *

Insurance ID / Member Number *

Group Number Optional — if shown on your card

Insurance Company Phone Optional — number on back of insurance card

Supplemental Insurance — optional

Supplemental Plan Name

Supplemental Member ID

Supplemental Phone

Medicare Beneficiary ID (MBI)

I don't have my Medicare card with me

Medicare Beneficiary Identifier (MBI) * Found on your red, white, and blue Medicare card.

Step 6 of 7

Clinical Questions

Help us set up your supplies correctly by answering a few quick questions about your care.

Please complete the required questions above.

Step 7 of 7

Insurance Card Photos

Upload photos of your insurance card so we can confirm your benefits and prevent billing errors.

Please upload or skip your insurance card photos.

💡

Tips for a clear photo

Make sure all text is visible and in focus
Place card on a dark, flat surface with good lighting
Avoid glare, shadows, and blurry edges

📋 Front of Insurance Card Required

📷

Tap to capture or upload

Camera on mobile · File picker on desktop

JPEG · PNG · HEIC | Max 10 MB

Processing…

Waiting for front photo

🔄 Back of Insurance Card Required

📷

Flip the card and capture the back