Enroll in Duke Medical Supply's Medicare Reimbursement Program

Enrolling is as Easy as 1 - 2 - 3

  1. ENROLLMENT FORM

    Complete the on-line Enrollment Form below

    - OR -

    Call us toll free at (1-888-678-6692) to request and enrollment and consent form.

  2. PATIENT CONSENT FORM

    A Patient Consent Form PDF must be completed and mailed to us. The form authorizes us to obtain a prescription from your physician and also allows us to bill Medicare on your behalf.

    Acrobat 5.0 or Higher PDF Viewer ius required to view PDF Documents. Download Acrobat Reader free.

  3. PRESCRIPTION

    When we have received your signed Patient Consent Form we will contact your physician's office to obtain a prescription for your supplies. We will then contact you to confirm your supply preferences and the date of your first shipment.

No strings attached - No long term commitment: You may cancel or suspend your supply shipments from Duke Medical Supply at any time.

If you have difficulty filling out the form, or if you would prefer to have an enrollment package sent to you, please do not hesitate to contact us as follows:

Toll Free: (1-888-678-6692)
Email: customerservice@dukemedicalsupply.com




Patient Enrollment Form
All fields marked with an asterisk (*) are required
Personal Information
* First Name & Middle Initial:   MI:
* Last Name:
* Address Line 1:
  Address Line 2:
  Suite:
* City:
* State:
* Zip Code + Four: + +four not required
* Phone Number:
  Email Address:
* Social Security Number:
* Date Of Birth: (MM/DD/YYYY)
  Height: ft  inches
  Weight: lbs
* Marital Status:
Insurance Information
* Is Medicare Your Primary Insurance? Yes    No
* Medicare Number:
* Part B Effective Date: (MM/DD/YYYY)
  Medicaid Number:
  Other Insurance Company:
  Insurance Phone Number:  Ext. 
  Insurance Effective Date: (MM/DD/YYYY)
  Policy or ID Number:
  Insurance Group Number:
  Insurance Plan Number:
Medical Information
* Physician's Name:
  Physician's Address:
  City:
  State:
  Zip Code:
* Physician's Phone Number: Ext.
* Approximate Date of Last Visit: (MM/DD/YYYY)
* Do you have a Colostomy? Yes    No
* Do you have an Ileostomy? Yes    No
* Do you have an Urostomy? Yes    No
* Do you use Intermittent Catheters? Yes    No
  What brand of supplies do you use?
  When is the best time of day to call?