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Product(s) you are enrolling for *

Diabetic Supplies
CPAP Supplies

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Name *

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Please enter your full name as it appears on your insurance card

Primary Phone Number *

Please indicate your daytime phone number

Date of Birth *

Email Address *

Please provide your email address for easy reorder and so we can keep in touch

Preferred Method of Contact

Billing Address *

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Do you have a different shipping address? *

If you answer YES, you will be required to provide a SHIP TO address below

Do you have your insurance card available? *

Please select "Yes" to enter your insurance information

Do you have supplemental/secondary insurance? *

If you have secondary or supplemental coverage, we can accept that as well. If you have primary Medicare, you may have a secondary or supplemental policy that covers your co-insurance/copay. This is typically called GAP Insurance or GAP Coverage. If you routinely pay a copay at your doctor's office, you may not have secondary coverage. If you have a Prescription Drug Plan, this MAY or MAY NOT include secondary coverage.

Best time to contact you *

Please indicate the best time of day to reach you

address? Billing Preferred

Have you seen your doctor within the last six months? *

Medicare requires on-going visits to your doctor. Please let us know if you have seen your doctor recently.

Do you have your doctor's information? *

Would you like to upload a current prescription or medical records? *

For faster processing, upload your prescription and medical notes to us. Don't worry we are HIPAA compliant and your data is secure and protected

Additional Notes:

Please indicate any additional information about your health condition

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