Medicaid Mary

Please complete this form. HDIS will call you to get started! Questions? Give us a call at 1-855-258-1138. Or email us at custcare@hdismedicaid.com.

Who will be using the medical supplies?

Myself

Another person

Have you seen a doctor or nurse practitioner in the past 6 months?

Yes

What is the last name of the doctor or nurse practitioner that was seen?

Provide your insurance information

State

Insurance Provider

Member ID

Select Item(s)

First name

Last name

Date of Birth

Sex

Street address

Apt, suite, unit, building, etc.

City

Zipcode

E-mail address

Phone number

Financial Responsibility

I accept financial responsibility for any charges not covered by my plan.

I also agree to HDIS's Privacy Policy as well as its Terms and Conditions.