Medicare/Insurance Form

Use this form to check for medicare/insurance coverage.

This form is required if you are going to purchase any of our products at prescription pricing.

General Information

All fields in this section are required!

First name:*
Last name:*
Email:*
Street Address:*
City:*
State:*
Zip Code:*
Phone #:*
Birth Date:*
Sex:*
Male Female

Medicare/Insurance Information

Insurance ID#:

Secondary Insurance

Secondary Ins. Policy #:
Group ID#:
Address:
City:
State:
Zip Code:
Telephone:

Physician

Primary Care Physician:
Telephone:
Fax:
Address:
City:
State:
Zip Code:

Signature and Disclaimer

*My initials or printed name entered below legally represent my signature signifying that all information I have entered above is mine and that I have been given the opportunity to read and do approve of the three forms directly below.

Hipaa Privacy Notice
Medicare Supplier Standards
AssignmentNotice

E-Signature:*

Code Below:*

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