Please fill out and submit the form below:

I have received the Diabetes Store, Inc. Customer Welcome Guide which includes but is not limited to the Notice of Privacy Practices, Customer Rights and Responsibilities, Complaint/Grievance Process, Mission Statement, Hours of Operation and Return Policy. I have also been informed of my financial responsibilities regarding any and all supplies received or to be received. Assignment of Benefits/Authorization for Payment – I request that payment of authorized Medicare and/or private insurance benefits to me or on my behalf be made directly to Diabetes Store, Inc. for any home medical equipment, supplies and services furnished to me by Diabetes Store, Inc. on or after January 1, 2019, in conjunction with my diabetes care and benefits. I authorize Diabetes Store, Inc. to seek such benefits and payment on my behalf. It is understood that, as a courtesy, Diabetes Store, Inc. will bill Medicare/Medicaid or other federally funded sources and other payer and insurer(s) providing coverage. I agree to pay all amounts that are not covered by my insurer(s) including applicable copayments and/or deductibles for which I am responsible.