Diabetes care Solution has partnered with Medical Supplies Express to deliver safe, affordable diabetic supplies direactly to your door with free shipping and handling for purchase over $25.
Blood Glucose Monitoring
With Oral Medication
With Diet & Excersice
Wavier of Liability /Medical Information Release
I request that my payments or payment of my insurance benefits ( Medicare, Medicaid or Private or HMO) be made to Diabetes Care Solution for any supplies or services furnished to me by Diabetes Care Solution. I understand that I am fully responsible to pay all amounts that are not covered by my insurance .I authorize any holder of medical information about me to release to Diabetes Care Solution any information needed to determine benefits payable for these supplies or services. In addition, I authorize Diabetes Care Solution to release my medical records to insurers as well as medical professionals. I authorize Diabetes Care Solution to contact me by telephone, email or mail regarding my medical supplies.
If patient has signed by making an 'x' due to language barriers or physical limitations, the signature and address of the witness should be entered next to the beneficiary's mark. If the patient is unable to sign due to a physical or mental condition, an Authorized Representative of the patient must complete the section below. By signing on behalf of the customer, you acknowledge that you have authority to do so.
My check or money order made payable to Diabetes Care Solution is enclosed (do not send cash).
Mail Order Form And Payment To