TH Direct Providers Business Capabilities Survey

DME/HME Providers Business Capabilities Survey

Please fill in the survey below to create an account with Tomorrow Health. Once complete, you and your team will receive account activation links and will be invited to schedule a training session. Please contact dmepartners@tomorrowhealth.com if you have any questions.
Please note this form is only designed for DMEPOS supplier companies. If you are a medical facility, doctor's office, and/or hospital please click here to fill out the appropriate form.
1. What is the name of your company?*
1a. Please list any additional company names or DBAs that your company may bill as or be known as:
2. Please enter the address(es) of your company's retail locations. Use the "+" button if there are multiple locations*
3. Does your organization have a phone number for urgent orders needed past 5:00 PM and weekend orders 9-5 PM? Please add it below.
4a. Please list all Taxpayer Identification Numbers (TIN) that your company may use for billing. Separate by comma. *
4b. Please list all National Provider Identifier (NPI) that your company may use for billing. Separate by comma. *
4a. Please list any additional TINs that your company many use for billing.
4c. Does your business qualify under any of the below Diversity Equity and Inclusion (DEI) designations? Please select all that apply.

Minority Business Enterprise (MBE)Women Business Enterprise (WBE)Veteran-Owned Small Business (VBE)Service-disabled Veteran Owned (SDVBE)LGBT Business Enterprise (LGBTE)Disabled Owned Business Enterprise (DOBE)Disadvantaged Business Enterprise (DBE)Small Business Enterprise (SBE)Small Diverse Business Enterprise (SDB)Small Business (SB)Women-Owned Small BusinessHUBZone – SBA
5a. Please provide the first and last name of the individual who will be the point of contact for the onboarding of your organization:*

First NameLast Name
5b. What is their email address?*
example@example.com
6. Do you support delivery for urgent, same-day discharge orders (e.g. for items such as oxygen, walkers, commodes, etc.)?

YesNo
7. Please select all the miscellaneous (E1399) adaptive aids products you are able to service.

Non-slip bathmatsPill boxStep StoolHandheld shower headsSock aidLong handled spongeReusable Cold PacksBio FreezeOTC Pain PatchesOTC 4% Lidocaine Patches or CreamSombra Gel (warming or cooling)Cotton Tipped ApplicatorsOral Swab SticksBody Cleansers and Foaming CleansersSharps ContainerWe do not dispense items under E1399 and A999Other
8a. Please confirm your dispensing capabilities for the nutrition brands below.*

BoostEnsureCarnation DrinksGerberNutramigenPedialyteGlucernaThick it- nutrition thickenerPeptamen JrJevityOsmoliteElecareKate FarmsCompleatNutrenIsosourceWe do not dispense nutrition products
8b. Please upload a file with any additional brands you service for nutrition.

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9.Please indicate your urgent discharge capabilities. If you do not service urgent orders please check “we do not service urgent orders”.

Rows	Same Day Supply Closet Capacity	Delivery to Hospital Same Day Capacity	Delivery to Home Same Day Capacity	Delivery during Business hours only (8 - 5PM/M-F)	Delivery via DropShip only
Oxygen Tanks
Oxygen Concentrator & Tanks
Nebulizers
Walker/ Rollator
Wheelchair
Hospital Bed
CPAP / BiPAP
Wound Care
We do not service urgent orders

10.Please indicate your dispensing capabilities per product categories below. Check all that apply.

Rows	Delivery via Driver	Shipping carrier	Patient picks up at location
Oxygen Tanks
Oxygen Concentrator
Nebulizers
Walker / Rollators
Wheelchairs
Hospital Bed
CPAP's
BiPAP's
Wound Care
Nutrition
Commodes
Diabetic Supplies
Incontinence
Ostomy

11.Do you service pediatric equipment? If yes, please indicate which categories you service for the pediatric population and for adults.

Rows	Pediatric	Adult
CPAP / BiPAP
Mobility
Nutrition
Oxygen / Pediatric Flowmeter
Ventilators / High-Tech equipment
Apnea monitor / Phototherapy

12. Tomorrow Health orders will be sent through our web-based platform. Please provide the names and email addresses of the individuals handling your organization's order intake. They'll receive an email from support@tomorrowhealth.com to set up their account on the platform. We suggest having at least 2-5 users. (Use the + button for multiple users)*
13. Please select all other insurances you are in-network with below. If selecting "Other", please use a semi-colon to list multiple health plans, or upload a list of insurances below.*

AetnaBCBS of MassachusettsBlue Benefit Administartors of MassachusettsCignaCommonwealth Care Alliance (CCA)ConnectiCare, Inc.Harvard PilgrimHealth New EnglandHumanaMass General Brigham Health PlanMassHealthTufts Health PlansUnited HealthcareUnited Healthcare Community Plan MAWellSense Health PlanMedicare Part BUnited Healthcare Dual Complete PlansWellcare of TexasAARP Medicare Advantage from United HealthcareBCBS of TexasWellpoint (FKA Amerigroup)TX MedicaidGeisinger CommercialGeisinger FamilyGeisinger GoldGeisinger Gold SecureSuperior HealthPlanOther
13. Please select all other insurances you are in-network with below. If selecting "Other", please use a semi-colon to list multiple health plans, or upload a list of insurances below.

AARP Medicare Advantage from United HealthcareAetnaAmeriHealth Caritas (CHC)BCBS of MassachusettsBCBS of TexasBlue Benefit Administartors of MassachusettsCignaCommonwealth Care Alliance (CCA)ConnectiCare, Inc.DMEnsionFallon HealthGeisinger Health Plan - FamilyGeisinger Health Plan - GoldGeisinger Health Plan - Gold SecureGeisinger Health Plan - KidsGeisinger Health Plan - MarketplaceHarvard PilgrimHealth New EnglandHighmarkHumanaIndependence Blue CrossKeystoneFirst CHCMass General Brigham Health PlanMassHealthMassHealth Primary Care Clinician (PCC)Medicare Part BMolina Healthcare of MassachusettsPA Health & WellnessPennsylvania Medicaid ACCESSTufts Health PlansTX MedicaidPA MedicaidMA MedicaidIL MedicaidOH MedicaidMI MedicaidUnited HealthcareUnited Healthcare Community Plan MAUnited Healthcare Dual Complete PlansUPMC Community HealthChoicesWellcare of TexasWellpoint (FKA Amerigroup)WellSense Health Plan
13b. Please upload a file with any additional insurance plans you are INN with.

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14a. Please list the counties by state that you are able to service urgently. Separate multiple entries with a comma (or upload list of counties or zip codes you are able to service urgently below).

Rows	List the counties you are able to service urgently. Separate multiple entries with a comma.	Additional comments
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY

14b. Upload list of counties or zip codes you are able to service urgently

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Please list the counties by state that you are able to service urgently.
15. What Order Management System (OMS) solution do you use today?*

BrightreeNiko HealthBonafideTIMSDMEWorks!Custom / home-grown systemWe do not use a system, we manually track referralsOther
16. Which accrediting body is your organization currently accredited by for DMEPOS services? (Select all that apply)*

The Joint Commission (TJC)Accreditation Commission for Health Care (ACHC)Community Health Accreditation Partner (CHAP)Healthcare Quality Association on Accreditation (HQAA)Board of Certification/Accreditation (BOC)The Compliance Team (TCT)National Association of Boards of Pharmacy (NABP)National Healthcare Accreditation (NHA)DNV HealthcareNot currently accreditedOther
17. Please upload proof of your accreditation

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DME/HME Providers Business Capabilities Survey