DMEPOS Providers Business Capabilities Survey
What is the name of your company?
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Please enter the addresses of your company's retail locations. Use the "+" button if there are multiple locations
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What is your company's TIN #?
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Pick one individual on your order intake team who can coordinate establishing your account. That individual can then extend the invite to other colleagues.
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First Name
Last Name
Pick one individual on your team who is responsible for order intake to initially establish your account. That individual can then extend the invite to other colleagues.
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What is their email address?
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example@example.com
What is their email address?
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What is their phone number?
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Area Code
Phone Number
What is their specific phone number extension?
Leave blank if no extension is necessary
What is their phone number?
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Do you have an after-hours phone number for urgent orders?
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Area Code
Phone Number
With which of the following insurance plans is your company contracted? Note: This may apply to GHP members with potential secondary coverage. (Select all that apply)
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Geisinger Health Plan - Gold
Geisinger Health Plan - Family
Geisinger Health Plan - Kids
Geisinger Health Plan - Marketplace
Medicare
Pennsylvania Medicaid ACCESS
Highmark
Independence Blue Cross
AmeriHealth Caritas (CHC)
PA Health & Wellness
KeystoneFirst CHC
UPMC Community HealthChoices
If applicable, in which of the following counties do you provide Home Delivery? (Select all that apply)
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ALL
NONE
Adams
Allegheny
Armstrong
Beaver
Bedford
Berks
Blair
Bradford
Bucks
Butler
Cambria
Cameron
Carbon
Centre
Chester
Clarion
Clearfield
Clinton
Columbia
Crawford
Cumberland
Dauphin
Delaware
Elk
Erie
Fayette
Forest
Franklin
Fulton
Greene
Huntingdon
Indiana
Jefferson
Juniata
Lackawanna
Lancaster
Lawrence
Lebanon
Lehigh
Luzerne
Lycoming
McKean
Mercer
Mifflin
Monroe
Montgomery
Montour
Northampton
Northumberland
Perry
Philadelphia
Pike
Potter
Schuylkill
Snyder
Somerset
Sullivan
Susquehanna
Tioga
Union
Venango
Warren
Washington
Wayne
Westmoreland
Wyoming
York
Do you have in-house delivery drivers for each of your retail locations?
Yes, we support same day deliveries
Yes, we support next day deliveries
We do not have in-house drivers
If applicable, please upload a spreadsheet that reflects the PA Counties that your team of in-house delivery drivers can serve for each of your individual retail locations. Please further notate those counties serviceable for same-day delivery for each individual retail location.
Browse Files
Note: This file must be submitted in Microsoft Excel.
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If applicable, if you receive an order before noon on a business day, what is the typical turn-around time for your in-house delivery drivers to fulfill this order within your coverage area? (Select all that apply)
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Same Day
Next Day
We do not have in-house delivery drivers
Do you have the ability to ship a portion of your inventory commercially from each of your company's retail locations? (e.g. USPS, UPS, FedEx, etc.)
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Yes
No
Please upload a spreadsheet that reflects your HCPCS capabilities for each of your company's individual retail locations. Please also include the TIN # for each retail location.
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Browse Files
Note: This file must be submitted in Microsoft Excel. If HCPCS vary by retail location, please indicate which locations carry which HCPCS.
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Some DMEPOS providers maintain an onsite supply of equipment & supplies at servicing provider offices, post-acute settings, and hospitals - commonly known as Supply Closets or Consignment. If applicable, please upload a spreadsheet that reflects your Supply Closet relationships for each of your company's individual retail locations.
Browse Files
Note: This file must be completed in Microsoft Excel.
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