v6 © 07-2008

DIABETIC SUPPLIES

Use your SHIFT LOCK * one patient

per submission

THIS APPLICATION IS USED FOR AN EXISTING PATIENT PROCESSING ONLY.
PROVIDER INFORMATION
Your Integrated Client Number or your name
IMPORTANT:
PLEASE - At Least Once Per Session of Claim Entry :
YOUR EMAIL ADDRESS:
PRODUCT INFORMATION

.
 .      

.Patient Name

(last name first name mi)

.Date of Delivery

.(MM - DD - YY)

.      
description qty charge

.
 TEST STRIPS box / 50 qty $
100 LANCETS qty $
GLUCOSE MONITOR qty $
CONTROL SOLUTION qty $
LANCET DEVICE qty $
Only Non-Participating Medicare Providers or claims for other than Medicare patients may use the providers price
.    

.

EVERY PATIENT- we must report to Medicare how many times a day all diabetic patients are ordered to test

Testing How Many Times A Day?

We do not need the RX number, NDC number or Lot number or Brand Name

text entry area

If check boxes can't be used, enter product info and QTY.

Also use this box for Client Name & Number if needed.

.

.

.ARE YOU ACCEPTING ASSIGNMENT ? If this claim is for a Medicare Claim *

.YES NO * ( only non participating Medicare providers may check NO )

.

Click to Submit ->