Free Diabetic Supplies Form

All information is Kept Completely Confidential

See if you Qualify for Free Diabetic Supplies

Step 1 of 3: Enter Diabetic Patient's Information

First Name
Last Name
Email
Gender Male Female
Primary Insurance Coverage
- Medicare Medicare HMO HMO Private or Commercial No Insurance

Step 2 of 3: Shipping and Contact Information

Address
City
State
Zip
Country
Daytime Phone Number
Home Phone, if different
Date of Birth
Name of Insurance Co.
Patient ID Number
Insurance Phone Number
Secondary Insurance Yes No
If Yes: Name of Secondary Insurance Company
Secondary Insurance Patient ID Number

Step 3 of 3: Medical Information

Physician's Name
Physician's Phone
Do you use insulin? Yes No
How many times a day are you testing?
I need a new meter Yes No
Brand of meter
Comments

Medical/Payment Release Authorization

Prior to shipping diabetic supplies, we are required by Medicare/Insurance Company to obtain your agreement to allow us to handle the billing on your behalf.  Agreeing to these terms now will help expedite the first shipment of your supplies upon verification of your health insurance. I acknowledge that by submitting this application, I am initiating the services of  AMERICANDIABETES.com.
I authorize the release of any medical or other information necessary for ADS to process and submit my claims to Medicare and/or my insurance.
I authorize payments for medical supplies furnished to me by AmericanDiabetes.com be paid directly to them.
I agree that if my insurance company sends me the payments, that I will send all of the payments received directly to ADS as soon as I receive them.
I give ADS permission to contact me by telephone concerning the furnishing of Medicare covered items that are to be rented or purchased.
I have reviewed the Notice of Privacy Practices available online and/or understand that I can request a printed copy.

I agree to the terms of the Medical/Payment Release Authorization. I understand that a paper copy of this Release will be mailed or included in the first shipment for me to sign and return immediately for company records.

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All information is Kept Completely Confidential