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Find out if your Diabetic supplies are covered by Medicare.

MedCareMD is a Medicare participating provider offering major brand name Diabetic Supplies for people primarily covered by Medicare. We can help you determine if your Diabetes Supplies are covered by Medicare.

- Please fill out the inquiry form below and submit. Required fields are noted with an*.
- A Care Coordinator will contact you and answer any questions you may have about Medicare coverage of Diabetic supplies, our service and help determine if you are covered.

There is no charge for this service and you are not obligated to buy anything. Or if you would prefer, call us now toll free at: (800) 844-1146.

* Required information
*First Name:
*Last Name:
*Telephone Number:
*Best Time to Call?	AM PM
Time Zone:
Address:
Suite/Apt#:
City:
State:
Zip:
E-mail Address:
Fax:
Date of Birth:
Medicare Number (if Applicable):

What is your Gender?
Do you have Diabetes?	Yes No
How many times a day do you test your blood?
Do you inject insulin?	Yes No
Enter any other information or questions here:

Primary Insurance Carrier:
Plan Number:
Group Number:
Insurance Phone Number:

Secondary Insurance Carrier:
Plan Number:
Group Number:
Insurance Phone Number:

Doctor Name:
City:
State:
Zip:
Telephone Number:
Fax:

I authorize a MedCareMD representative to contact me. (This must be checked in order to send this form)