Enroll

:: ENROLL NOW

Enrolling with USMED is simple! Just fill out the form below, submit it, and
we'll call you to complete your enrollment!
Note: Bold entries are required.

First Name:*

Middle: Last Name:*

Phone:*
- -

When is the best time to contact you?

Email Address: *

Street Address: (ex.123 Main St.)*

Address Line2: (ex.Apt.#)

Gender:*

Date of Birth: *
/ /
City: *
State: *	Zip Code:*
Social Security Number: (Optional)
- -

Physician's Name*	Physician's Telephone*
	- -

My Insurance is:

	My Medicare Number:
	Supplemental or Secondary Insurance Company Name (optional):
	Secondary Policy Number:
	Secondary Insurance Phone: - -

	Private Insurance Company Name:
	Private Insurance Policy Number:
	Private Insurance Group Number:
	Private Insurance Phone: - -

You must select an insurance type.

NO HMO's PLEASE

Did you receive a list of doctors
from your insurance company
from which you must choose
a primary care doctor?

Yes No (select one)

I am interested in:
	Check all that apply
	Diabetic Testing Supplies
	Breathing Medications
	CPAP Masks
	Vacuum Erection Device
	Heating Pads
Choose Gift:

* All required fields

**By clicking submit, you are authorizing United States Medical Supply to contact you
by telephone and email.