↓ Skip to Main Content
Call Us
1-888-678-6692
ENROLL TODAY
Home
Ostomy
Medicare Ostomy Coverage
Ordering Your Ostomy Supplies
Ostomy Products
Catheters
Medicare Catheter & Urological Coverage
Ordering Your Urological Supplies
Catheters & Urological Products
Products Catalog
About Us
How We Work
Return Policy
Privacy Policy
Notice of Privacy Practice
Resources
Form Center
FAQs
Medicare Facts
Contact
Enroll Form
Home
›
Enroll Form
Online Enrollment
Is Medicare Your Primary Insurance?
*
Yes
No
If Medicare is not your primary form of insurance, please call a Duke Representative at
1-888-678-6692
to learn if we can help you.
Full Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Email
Previous Supplier
*
Yes
No
If Yes, Approximate Date of Last Order
MM
DD
YYYY
Insurance Information
Medicare Policy ID
*
Please provide your most current Part B Medicare policy ID. This will be a 10 digit number followed by a letter, letter/ number combination, OR an 11 digit alphanumeric code. Dashes not required.
Part B Effective Date
*
MM
DD
YYYY
Do You Have Medicaid?
*
Yes
No
State
Medicaid Number
Other Insurance Company
Insurance Phone Number
Insurance Effective Date
MM
DD
YYYY
Policy or ID Number
Insurance Group Number
Insurance Plan Number
Do You Have an Ostomy
*
Yes
No
If yes, please select all that apply
Colostomy
Ileostomy
Urostomy
Do You Use Catheters?
*
Yes
No
If yes, please select all that apply
Intermittent
External
Foley
Medical Information
Physician's Name
*
Physician's Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Physician's Phone Number
*
Physician's Fax Number
Approximate Date of Last Visit
*
Email
This field is for validation purposes and should be left unchanged.
