Managed Care
Organization

 
 

Trace Medical and SunMED Medical Solutions have executed an exclusive long-term Network Administration Agreement to provide ventilator rentals to their entire SunMED Managed Care Organization (“MCO”) Network, Workers Compensation and customer base of over 500 insurance providers.

If you have an opportunity to support a ventilation patient and your company is out of network with the MCO, please submit the following form or download and print to submit. We will process your order immediately and contact you within one business day.

Patient Name *
Patient Name
Date of Birth *
Date of Birth
Patient’s Cell Phone Number *
Patient’s Cell Phone Number
Permission to text obtained *
Permission to leave message obtained *
Patient's Home Phone *
Patient's Home Phone
Permission to leave a detailed message on this line obtained *
Patient's Address *
Patient's Address
Caregiver's Name *
Caregiver's Name
Caregiver's Phone *
Caregiver's Phone
Ordering Physician *
Ordering Physician
Physician's Phone *
Physician's Phone
*
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone Number *
Emergency Contact Phone Number
Primary Insurance
Effective Date *
Effective Date
Insurance Phone Number *
Insurance Phone Number
Policy Holder (Primary Insured) *
Policy Holder DOB *
Policy Holder DOB
Insurance Carrier Address *
Insurance Carrier Address
Secondary Insurance
Effective Date
Effective Date
Insurance Phone Number
Insurance Phone Number
Policy Holder (Primary Insured)
Policy Holder DOB
Policy Holder DOB
Insurance Carrier Address
Insurance Carrier Address
Ventilator Type *
HCPCS Selection *
DME Phone Number *
DME Phone Number
DME Address *
DME Address
Respiratory Therapist Name *
Respiratory Therapist Name
Respiratory Therapist Address *
Respiratory Therapist Address

* Required Information

Download the form

If you would like to learn more about how Trace Medical and SunMED Medical can partner with you, please contact Elliot Campbell at ECampbell@TraceMedical.com