Form Information
Please read the following information regarding each form. You may also call one of our Customer Service representatives at 1-800-453-9033 for more information. We will be happy to answer any questions you might have.
Adobe Reader Required for the forms

• LOG - The Log is a Medicare requirement for people who are testing above the recommended threshold for each type of diabetes. For Type I diabetics the threshold is three, and for Type II diabetics the threshold is one. If your doctor has instructed you to test more than the Medicare threshold, please print and complete this log.
• SYRINGE ORDER FORM ­ We are pleased to offer low-cost syringes to our insulin-dependent Medicare customers. This is a service that we hope will make obtaining your diabetic supplies more convenient. For only $12.00 per box of 100, you can receive syringes with your regular shipment of supplies. Simply print the Syringe Order Form, complete the bottom portion, and mail to American Diabetic Supply, Inc. along with your personal check. All orders must be prepaid, so please allow plenty of time for your order to be received and processed prior to your next 3-month shipment.
• PATIENT AUTHORIZATION FORM ­ American Diabetic Supply, Inc. cannot bill your insurance company for supplies that we send to you without your authorization. After signing up for our service by speaking with a Customer Service representative, simply print and complete this form and mail it to American Diabetic Supply, Inc.
  PHYSICIAN'S ORDER FORM ­ The Physician's Order is a form that American Diabetic Supply, Inc. must obtain to send supplies to you. In most cases, we will be able to obtain this form on your behalf. An American Diabetic Supply Customer Service representative will contact you if your assistance is needed. 
   
• PRIVACY POLICY INFORMATION ­ 
  This Notice becomes effective on April 14, 2003.  We are required by law to maintain the privacy of your protected health information.  We are obligated to provide you with a copy of this Notice of our legal duties and our privacy practices with respect to protected health information and we must abide by the terms of this notice.  We reserve the right to change the provisions of our Notice and make the new provisions effective for all protected health information that we maintain.  If we make a material change to our Notice, we will mail a revised Notice to the address that we have on record for you.