Serving Diabetic Patients Since 1999
Serving the DFW Metroplex & Surrounding Areas

Toll Free 1- 866 - 640 - 5526
Espanol 817 - 271 - 6163

Convenient In-Home Service
Licensed Medicare & Medicaid Provider
Products
Shoes, Inserts & Gauntlets
Restorative Orthotics
Respiratory Equipment
Wheelchairs & Cushions
Hospital Beds & Cushions
Walking Aids
BioFreeze
Accessories & Other Equip.
 
 
Referral Form
TSR Medical Referral Form

How does the referral process work?

  
Step One:
You call, fax or use the form below for your referral for the patient. Then we log the patient into our database, and get to work!
Step Two:
We contact the patient and obtain all necessary information and set up an in-home delivery. For customized products, such as Shoes/Inserts/Gauntlets and Restorative Orthotics, we set up an in-home evaluation to obtain the proper measurements.
 
Step Three:
Upon receipt of customized products (Shoes/Inserts/gauntlets and Restorative Orthotics), we contact the patient and set up an in-home delivery.
**For insurance purposes, all equipment must be prescribed by either a M.D., D.O., N.P., D.P.M., etc.
 
Step Four:
After all required documentation is received, we bill the insurance company(ies).
 
Online Referral Form
* Required
Patient Information
Name:*
Area Code & Phone:*
Date of Birth:
Address:
City:
State:
Zip Code:
Medicare #:
   
Referral Source Information
Your Name:*
Area Code & Phone:*
Email:
Dr.'s Name:
Upin#:
ICD-9 Codes (Separate multiple codes with commas)
Name of your company or Dr. Office:
Please select all products/services that are required:*
To select multiple items press the Ctrl button on your keyboard and click your mouse on the items you want
Accessories & Other:
   
Note: To speed up the process make sure you have completed the Address, City, State, Zip, Date of Birth, Medicare# and the appropriate product/service fields.
 
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