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Medical Equipment Provider Questionnaire

Please complete form and send to Network Relations Department.

Legal Company Name:
D/B/A Name
Physical Address
  City
State Zip
Remit to Address
  City
State Zip
Phone
Alternate Phone
Fax
Email
Website
Contact Person & Title
Counties Served
Years in Business
Hours of Operation
Federal Tax ID
Delivery Hours?
Do you offer on call services? Yes No
Required to have State License to provide services? Yes No
Certification Held
Do you have processes in place to verify current licensures and certifications? Yes No
Do you subcontract any of your services? Yes No
If yes, What services and who credentials these subcontractors?
Do you service/repair DME Equipment? Yes No
If yes, what items are you capable of servicing /repairing in-house?
What item(s) do you supply from your in-house inventory?

 

ADLs
Powerchairs
O&P
Dynamic splints
Wheelchairs
Bracing
Grab Bar Install
Bath Aids
Soft Goods
Lift Chairs
Lifts
Traction
 Cold Therapy
Game Ready
EMS
Bariatric DME
CPMs
Rehab Seating/Positioning
Specialty Mattresses
Beds
Infusion Therapy
Respiratory Products
Monitors/Pumps
Static Progressive Splints

Other

I attest that the information on this application is correct and complete. I agree to notify Total Medical Solutions within 30 days of any changes to the information contained herein.