Reliable Diabetes - Supply Refill Form

1
Select the Diabetes supplies that you would like to order* This field is required.If you are currently not receiving an item from us but would like to, please select that item as well!
Sensors (max quantity allowed by insurance)
Transmitters (max quantity allowed by insurance)
Infusion sets (max quantity allowed by insurance)
Cartridges (max quantity allowed by insurance)
2
Endocrinologist Appointments
Date of Last Appointment
Date of Next Appointment
Provider Name
3
Please include any additional information, including changes (if any) to your health insurance, doctor, or your prescription.
4
Confirmation of Medical Necessity* This field is required.1. These items remain reasonable and necessary, my existing supplies are approaching exhaustion, and I have indicated any changes to my order in the previous section. 2. Medical Information Authorization. Customer authorizes any holder of medical information relating to said Customer to release to Reliable Respiratory any record pertaining to his or her medical history, services rendered, or treatment. Customer authorizes Reliable Respiratory to release Customer’s medical information to appropriate accreditation and insurance company personnel and other health care related organizations. Customer authorizes use of email to communicate with these organizations. 3. Assignment of Insurance Benefits. Customer authorizes any and all Medicare or other insurance benefits to be paid directly to Reliable Respiratory for any services or equipment furnished to Customer by Reliable Respiratory.
I confirm
5
Please complete the following information. By submitting this form you are confirming the terms below.* This field is required.1. These items remain reasonable and necessary, my existing supplies are approaching exhaustion, and I have indicated any changes to my order in the previous section. 2. Medical Information Authorization: Customer authorizes any holder of medical information relating to said Customer to release to Reliable Respiratory any record pertaining to his or her medical history, services rendered, or treatment. Customer authorizes Reliable Respiratory to release Customer’s medical information to appropriate accreditation and insurance company personnel and other health care related organizations. Customer authorizes use of email to communicate with these organizations. 3. Assignment of Insurance Benefits: Customer authorizes any and all Medicare or other insurance benefits to be paid directly to Reliable Respiratory for any services or equipment furnished to Customer by Reliable Respiratory.
Electronic Signature
Date Of Birth
Please enter your email (for patients responding by text)
Delivery address for this order
Should be Empty: