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Diabetic Solutions & Medical Supply
Diabetic Solutions and Medical Supply
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MEDICARE RECIPIENTS REGISTER 877-881-0804-(915)881-0800
> Medicare Coverage Form
Diabetic Solutions Delivers diabetes supplies and Medical equipment including wheelchairs,power wheelchairs,diabetic shoes,walkers,arthritis relief t pumps,and great variety of medicare,medicaid covered medical equipment.
Medicare Coverage Form
Item#
newitem88564381
face="arial,
helvetica">
Fill:
out
form
and
an
expert
will
contact
you
to
help
you
find
your
best
option
of
coverage.
<P>
<b>3
easy
steps.
<P>
<b>step
1
Your Information
<P>
<b>Your
Name:</b><br>
<input
type="text"name="Name"
size="27">
<p>
<input
type="text"name="Name"
size="27">
<p>
<b>Your
Middle
Name:</b><br>
<input
type="text"
middle
name="Name"
size="27">
<p>
<b>Last
Name:</b><br>
<input
type="text"
name="last
name"
size="27">
<p>
<b>Gender:</b><br>
<input
type="text"
Male-Female="Male-Female"
size="2">
<p>
<b>Street
Address:1</b><br>
<input
type="text"
street="street
name"
size="27">
<P>
<b>Street
Address:2</b><br>
<input
type="text"
street="street
name"
size="27">
<p>
<b>city:</b><br>
<input
type="City"city="city
name"
size="27">
<p>
<B>
Zip
Code:</b><br>
<input
type="text"
street="street
name"
size="7">
<p>
<b>Email
Address:</b><br>
<input
type="text"email="email
address"
size="27">
<P>
<b>Phone
Number:</b><br>
<input
type="text"
phone="phone
number"
size="12">
<P>
<b>Alternate
Phone
Number:</b><br>
<input
type="text"
phone="
alternate
phone
number"
size="12">
<P>
<b>step
2
Insurance information
<P>
<b>physicians
Name:</:</b><br>
<input
type="text"
name="physicians
Name"
size="27">
<P>
<b>step
3
physicians information
<P>
<p>physicians
phone
number:</b><br>
<input
type="text"physicians
phone="
physicians
phone
number"
size="12">
<P>
<b>Medicare
Number:</b><br>
<input
text
type="text"medicare
number="number"
size="27">
<P>
<b>Enter
Secondary
Insurance
Carrier:</b><br>
<input
text
type="text"secondary
insurance
carrier
number="number"
size="27">
<P>
<b>Enter
Secondary
Insurance
Phone
Number:</b><br>
<input
type="text"
phone="
secondary
insurance
phone
number"size="12">
<P>
<b>Enter
Social
Security
Number
(000-00-0000):</b><br>
<input
type="text"social
security
number="social
security
number"size="9">
<P>
<b>How
often
do
you
test
your
blood
sugar
level?</b><br>
<input
type="radio"
name="Visit"
value="1
time
daily
> 1 time daily<br> <input type=
radio"
name="Visit"
value="2
times
daily
> 2 times daily<br> <input type=
radio"
name="Visit"
value="3
times
daily
> 3 times daily<br> <input type=
radio"
name="Visit"
value="4
times
daily
> 4 times daily<br> <input type=
radio"
name="Visit"
value="5
times
daily
> 5 times daily<br> <input type=
radio"
name="Visit"
value="6
times
daily
> 6 times daily<br> <input type=
radio"
name="Visit"
value="7
times
daily
> 7 times daily<br> <input type=
radio"
name="Visit"
value="8
times
daily
> 8 times daily<br> <input type=
radio"
name="Visit"
value="9
times
Daily
> 9 times daily<br> <input type=
radio"
name="Visit"
value="10times
Daily
> 10times daily<br> <p>
Please:
add
any
comments
you
have
below:</b>
</font><br>
<textarea
cols="40"
rows="10"
name="Comments"></textarea>
:
<input
type="submit"
value="Send">
<input
type="reset"
value="Clear
the
form">