Med-Care: America's First Choice In Diabetic Supplies

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Med-Care Diabetic Inc 902 Clintmoore Rd STE 214, Boca Raton, FL 33487 Toll Free: 800-407-0109, Fax: 1-877-866-2664

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Patient Agreement - Assignment of Benefits
I authorize Med-Care Diabetic Supplies to contact me by telephone, mail, or e-mail to discuss products and services that may be available to me. I authorize Med-Care Diabetic Supplies to exchange information with my physician, insurance company, Healthcare Finance Administration or Employer as necessary to verify my benefits and to submit insurance claims on my behalf for the dispensed supplies. I also authorize payment of medical benefits related to the dispensed supplies of Med-Care Diabetic Supplies. This authorization shall extend to all claims submitted by Med-Care Diabetic Supplies. By signing this, I agree to provide Med-Care Diabetic Supplies with any reimbursement I might receive from my insurance company for the dispensed supplies and accept responsibility for all charges not paid by my insurance company. I agree to be responsible for all collection costs in the event my account is not paid in a timely manner. I agree to pay all collection costs and reasonable Attorney's fees, which I agree shall be thirty-three and a third percent (33.3%) of the balance of any delinquent account.
Physician Section
1. Diagnosis Code - (ICD-9):
250.01 (IDDM) 250.00 (Insulin Req) 250.00 (Non Insulin Req) Other
2. Testing Frequency - (Testing per Day):
1X 2X 3X 4X Other
3. Injection Frequency - (Injections Per Day):
None 1X 2X 3X 4X Other
4. Documentation - (Statement regarding the necessity of additional strips above the Medicare utilization guidelines) Insulin Req = 3X per day Non Insulin Req = 1X per day
Required:
5. I Prescribe
All Supplies Below Or Only checked Supplies
Monitor Strips Lancet Lancing Device(PRN) Control Solution Battery Syringes 1/2 cc Syringes 1 cc
It is my professional opinion that the items listed above are reasonable and medically necessary. I also acknowledge that I have seen and evaluated the above-mentioned patient within 6 months prior to ordering quantities of strips and lancets that exceed Medicare guidelines if applicable. The patient and / or caregiver are able to follow instructions for controlling diabetes and able to use these ordered supplies. I agree to maintain the original signed Enrollment Form in the patient's medical records.

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