For Your Diabetic Supplies Choose American Diabetic Supply, Inc.

Contact Us
Enroll

Call 1-800-453-9033 today and immediately enjoy the advantages provided by your health care plan. If you prefer to have one of our representatives call you, please complete the following information, select Submit, and a member enrollment representative will call you in two working days or less.

After receiving the following information, a member enrollment representative will verify your insurance and then call you to discuss your coverage and benefit options. This insurance evaluation is a free service provided by American Diabetic Supply, Inc., and you are under no obligation to order.

Please call me with information about your products and services.

Personal Information:

Name: First & Last:
Primary Phone:
Date of Birth:
Zip Code:
Email:

Physician Information:

Are You Taking Insulin?	How many times a day do you test?
Physician's Name:
Phone:

Insurance Information:

Complete this section if your private insurance is primary. We will need ALL the information in order to verify benefits with your insurance company. NO HMO’S PLEASE

Medicare #:	(please include all alpha and numeric characters)
Primary Insurance Company Name:
Primary Insurance Policy number:
Secondary Insurance Company Name:
Secondary Insurance Policy number:

Comments:

Please type any additional items required here.

Your annual deductible or co-pay may be payable to American Diabetic Supply, Inc.

"By submitting this information, I authorize an American Diabetic Supply, Inc. representative to contact me by telephone to confirm the information that I am submitting and to inquire as to additional information that American Diabetic Supply, Inc. may require."