Apply for Our Services 

If you prefer to Mail or Fax the Application to us:

To apply for our services there are two forms that we will need for you to print, complete and mail/fax to us:

1. Patient Application Form
2. Medical/Payment Authorization Release

Note:  these forms will require Adobe Acrobat.  If you do not already have Acrobat Reader:

If you are on Medicare, and do not have any supplemental insurance, and believe that the Medicare 20% co-payment would be a great financial hardship, you may apply for our Financial Hardship Assistance Program.  Please call one of our associates for details.

Mailing Address:

American Diabetes Services
7301A W. Palmetto Park Road, Suite 101C
Boca Raton, FL  33433

Faxing Option:

Toll-Free Fax Number: 1-877-416-5438

If you prefer to use our Online Application:

Visit Apply Now for Supplies