Massachusetts HME Providers Business Capabilities Survey

1a. What is the name of your company?

1b. 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 and fill out all information below. Use the "+" button if there are multiple locations.

3. Does your organization service for urgent orders past 5:00 PM on weekdays and/or weekend orders? If so, please input it below.

4a. Please list all Taxpayer Identification Numbers (TIN) that your company many use for billing. Separate by comma.

4b. Please list all National Provider Identifier (NPI) that your company many use for billing. Separate by comma.

4b. 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.

5. What is your MA State License #?:

5a. Which bodies is your company are accredited with?

Other

5b. Please upload proof of accreditation

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6. What is your fax number?

7a. 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

7b. What is their email address?

example@example.com

8. Please indicate your dispensing capabilities per product categories below. Check all that apply. Note: You can adjust these selections on the HCPCS level later.

Rows	Deliveries via Driver	Deliveries via shipping carrier	Urgent Deliveries (Same Day)	Pediatric Referrals	Adult Referrals
Walkers & Rollators
Ventilators
Transcutaneous Electrical Nerve Stimulators (TENS)
Tracheostomy Supplies
Therapeutic Shoes
Surgical Dressings
Standard Wheelchairs
Prosthetics
Pressure Reducing Support Surfaces
Power Mobility
Pneumatic Compression
Patient Lift
Oxygen Contents & Equipment
Ostomy Supplies
Orthopedic Braces
Nutrition
Negative Pressure Wound Therapy
Nebulizers
Incontinence Supplies
Hospital Beds
Diabetic Shoes
Diabetic Supplies
Custom Burn Garments
Cough Assist, Stimulators and Vest Therapy
Catheters
Canes, Crutches, Knee Scooters
CPAP
Breast Pumps
Blood Pressure Monitors
Biliblankets
BiPAP
Bathroom and Bedroom Aids

9. Please indicate your dispensing capabilities for the following item that are dispense under HCPC E1399 and A999.

10. Please confirm your dispensing capabilities for the nutrition brands below.

10a. Please upload a list of any other nutrition brands that you service below

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11. 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)

12. Are you currently in-network with Commonwealth Care Alliance (CCA)?

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.

Please upload a list of any other insurances you are in-network with below

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14. Please select all counties in Massachusetts that you service:

15. Please select all counties in Massachusetts that you service URGENTLY:

16. What Order Management System (OMS) solution do you use today?