Step 2: Rx Outreach Qualifications, Find out If You Are Eligible

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1 - 800 - 209 - 6057

Complete and sign the application

To Enroll, Please Fill Out Each Field
MaleFemale

Shipping address if different form above(Your shipping address must be a deliverable U.S Post Office street address):

Income Information:

Doctor

Social Service Organization

Clinic/Healthcare Facility

Self/Family

Other

You must the form before we can send your mediciness.I attest that information provided in this application is complete and accurate.This authorization or a copy shall be valid for 12 months form the date of signature.I understand that Diabetes Care Solution reserves the right to request income verification form me or refuse my application based on any misuse, abuse or illegal distribution of any products in this program. I will not seek reimbursement of any feel Ipay to Diabetes Care Solution form my health insurance, including Medicaid, Medicare or similar programs.

(If advocate/guardian signing on befhalf of patient-please denote relationship and complete below)

Event Code: 788

If Placing An Order

How to pay:Check or money order payable to Diabetes Care Solution, Or credit Card.Please do not send cash.

Visa

MasterCard

Discover

FAS

I authorize Diabetes Care Solution to charge this credit card for payment on my fist order.