DMEPOS Providers Business Capabilities Survey

DMEPOS Providers Business Capabilities Survey
What is the name of your company? *
Please enter the addresses of your company's retail locations. Use the "+" button if there are multiple locations *
What is your company's TIN #? *
Pick one individual on your order intake team who can coordinate establishing your account. That individual can then extend the invite to other colleagues. *

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. *
What is their email address? *
example@example.com
What is their email address? *
What is their phone number?

Area Code Phone Number
What is their specific phone number extension?
Leave blank if no extension is necessary
What is their phone number? *
Do you have an after-hours phone number for urgent orders?

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) *

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) *

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.

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Note: This file must be submitted in Microsoft Excel. Cancel of
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) *

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.) *

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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Note: This file must be submitted in Microsoft Excel. If HCPCS vary by retail location, please indicate which locations carry which HCPCS. Cancel of
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. Cancel of
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