WELCOME! CAST21 Patient Interest Form by Truthful Medical

WELCOME! CAST21

CAST21 SUPPLIED BY TRUTHFUL MEDICAL LLC
PATIENT INTEREST FORM
Today's Date

MonthDayYear
Date
Your Name*

First NameLast Name
Are you the patient?
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Location:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you under the care of a physician?*

Yes I have a physician that has agreed to apply CAST21Yes, I have a physician but have not discussed CAST21 yet
Physician Choice (CAST21 must be applied by a Healthcare Professional)

I would like my physician to apply CAST21I would like any certified doctor in my area to apply CAST21Either my physician or any certified doctor in my area is acceptable
Is your physician certified to apply CAST21?

YesNoI do not know
You have not yet contacted your physician, no worries! We will assist you and provide certification to your physician. Please choose one:

send me an email containing the instructions on how to properly contact my physician in order to formally request CAST21I will locate the email address of my doctor and would like you to communicate with them regarding my request after I provide it to youI have the email address of my doctor now and would like you to communicate with them regarding my request
Physician's FULL Name (First and Last Name Required)*
Please provide the full name and NPI number if possible, as this will expedite your request. The NPI number is available my googling or by using this database: https://npiregistry.cms.hhs.gov/search
Upcoming appointment? Let us know the date and we will expedite your request!

MonthDayYear
My upcoming appointment date
CAST21 is considered a covered item by most health insurance plans. Many plans will allow members to self pay and submit a claim for reimbursement. Please let us know if you are interested in this after submission.
Please select the option that best describes you:*

I have active healthcare coverage and would like to know my coverageI have a high deductible plan and would like to purchase self pay at a discounted rateI would like CAST21 urgently and would like to self pay ASAPI am self-pay and do not have insurance coverage
Great! After you submit this form, you will be given the option to proceed with adding your insurance information
CAST21 Size (scroll down for measurement guide)
CAST21 Preferred Color (scroll down for pictures)
CAST21 Second Choice Color
We're interested in understanding how we can help you! Please send us a message and we will reply with urgency! PLEASE NOTE: CAST21 IS ONLY AVAILABLE IN SHORT ARM CAST AT THIS TIME. IT IS NOT AVAILABLE FOR FOOT & ANKLE YET.
Please verify that you are human
GENERAL MEASUREMENT GUIDE

This is a general guide. CAST21 certified staff are provided with CAST21 measuring tapes. BOTH measurements are needed to evaluate fit
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Should be Empty:

WELCOME! CAST21

PATIENT INTEREST FORM

Great! After you submit this form, you will be given the option to proceed with adding your insurance information

GENERAL MEASUREMENT GUIDE