Free Diabetic Supplies Form

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  AMERICAN DIABETES SERVICES (ADS).
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 ADS 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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Diabetic Supplies from Support Plus Medical

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