PATIENT
AUTHORIZATION FORM
In order for American
Diabetic Supply, Inc. to send supplies to you and to receive
reimbursement directly from your insurer, you must sign and date this form
and return it to us.
Please contact us at 1-800-453-9033 if you should have any questions.
PLEASE
PROVIDE THE FOLLOWING INFORMATION:
Name:_________________________________________
Address:______________________________________
State/ZIP:____________________________________
Phone:________________________________________
Date of Birth:________________________________
Social Security:______________________________
Medicare #:___________________________________
Or
Private Ins. #:_______________________________
I, ________________________________,
authorize the release of any necessary medical information and
payment of medical benefits for services and supplies that I
receive to American Diabetic Supply, Inc. I understand that I
am responsible for all deductible and applicable co-insurance
amounts that are not covered by or are denied by my insurance.
I will notify American Diabetic Supply, Inc. promptly of any
changes that will effect insurance reimbursement.
I am not currently a
member of an HMO.
I am not receiving supplies
from another diabetic supply company. You may contact my Physician to acquire
any needed Physician Orders or renewals.
SIGNED (X) ________________________________________
DATE (X) _____________________________
American
Diabetic Supply, Inc.
A
Medicare Approved Provider
400 S. Atlantic Ave., Suite 108
Ormond Beach, FL 32176
1-800-453-9033
E-Mail
Us at
sales@americandiabeticsupply.com
