test page – Safe Place Bedding

Insured State*

State

Select Your Safety Bed*

Frame color

Cover Style

Bed Size

Incontinent Supplies Check list

Briefs Style (has sticky tabs on sides)

Pull Up Style (looks more like underwear)

Washable Bed Chux Set of 6

Gloves

Vinyl Glove

Nitrile Glove

Mobility

Transfer Bench with Backrest

Wood Transfer Boards

Transfer Bench and Commode

Bathroom Assistant Devices

Pediatric/ Small Adult Shower Chair 15" Internal Width, Open Front Seat, 3" Twin Brake Casters

Aluminum Shower Chair with Back

Shower Chair with Backrest and Padded Armrests

3.5" Elongated Toilet Seat Riser with Arms

Medline 5" Raised Locking Toilet Seat

5" Economy Toilet Seat Riser

Patient First Name*

Patient Last Name*

Caregiver First Name*

Caregiver Last Name*

Relationship*

Email Address*

Caregiver's Phone Number*

Patient Gender*

Male

Female

Primary Insurance*

Member ID*

Upload an image of your insurance card (front)*

Accepted file types: jpg, jpeg, png, Max. file size: 128 MB.

Upload an image of your insurance card (back)*

Accepted file types: jpg, jpeg, png, Max. file size: 128 MB.

Secondary Insurance (if applicable)

Secondary Member ID

Upload an image of your secondary insurance card (front)

Accepted file types: jpg, jpeg, png, Max. file size: 256 MB.

Upload an image of your secondary insurance card (back)

Accepted file types: jpg, jpeg, png, Max. file size: 256 MB.

If we are out of network with your insurance, is it okay if we use a partner DME who is in contract?

Yes

Patient's DOB*

MM slash DD slash YYYY

Cardholder DOB*

MM slash DD slash YYYY

NPI Physician*

This field is hidden when viewing the form

Physician/ Doctor Name

Physician Phone

Physician Fax

Shipping Address*

Street Address Street Address 2 (Optional - Lot/Apt #) City State ZIP Code

Where did you learn about us?

Tell us more

Concent*

I accept terms and conditions.*

Concent*

I accept assignment of benefit.*

TrueSight Api integration