Us Ostomy
 
Call: (800) 866-3002
2350 Airport Freeway, Suite 230
Bedford, TX 76022-4010

 
 

 
 

Ostomy Patient Medical Enrollment

  1. ENROLLMENT FORM

Complete the ostomy patient medical enrollment form and mail it to us.

- OR -

Call us toll-free at (1-800-866-3002) to request an enrollment and consent.

ENROLLMENT FORM


2. PATIENT CONSENT FORM

A Blanket Assignment, also known as Consent Form, should be completed and mailed to us. The form authorizes us to obtain a prescription from your physician and also allows us to bill Medicare on your behalf.

PATIENT CONSENT FORM


3. PRESCRIPTION

When we have received your signed Patient Consent Form, we will contact your physician's office to obtain a prescription for your supplies. We will then contact you to confirm the preferences of your ostomy medical supplies, as well as the date of your first shipment.


No strings attached - No long-term commitment: You may cancel or suspend your supply shipments from U S Ostomy Supply at any time.

If you have difficulty filling out the ostomy patient medical enrollment form, or if you would prefer to have an enrollment package sent to you, please do not hesitate to contact us as follows:

Toll Free: (1-800-866-3002)

Email: contact@usostomy.com