PRODUCT & SUPPLY ORDER

We do all of the hard work for you.

  • We verify insurance
  • We contact your provider
  • We ship directly to you

You may be responsible for any co-payments and/or deductibles that is required by your insurance plan.

Please describe what type of information you are looking for

Patient Information

First Name *

Last Name *

Date of Birth *

Mailing Address *

City *

State *

Zip *

Medical Provider Information

Treating Doctor/Provider Name *

Clinic/Facility Name *

Clinic Location *

Insurance Information

Primary Insurance Company *

Insurance ID# *

Group #

Contact Information

Parent/Guardian Name *

Parent/Guardian Name *

Parent/Guardian Relationship *

Your Email Address *

Contact Phone Number *

Orders are processed and shipped/mailed the following business day. We will contact you by phone, at the contact number provided above, if we are unable to process the order or if we require additional information.

*Note: Charges will be submitted to your health insurance company. The insurance company determines the allowable charge amount for the item(s) and then applies your individual coverage. For example, if your deductible has been met for the year, you will likely not have any out of pocket expense for covered supply items. However, if the deductible has not been met, your insurance company will determine the allowable charges and apply them to your deductible. We will bill you for the portion your insurance company determines is your responsibility.

Comments/Questions

Would you like to be contacted via telephone prior to the processing of your order?*