v5 © 12-2006

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 $
GLUCOSE MONITOR BATTERY ( ea. )

qty
$
Only Non-Participating Medicare Providers or claims for other than Medicare patients may use the providers price
.    

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

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

IT IS RECOMMENDED THAT YOU INCLUDE THE MANUFACTURER'S STOCK NUMBER FOR ALL OSTOMY ITEMS TO ENSURE PROPER IDENTIFICATION AND CODING :

NOTE: We Don't Need The Brand Name

text entry area
.

.

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

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

.
Make This Patient A Diary Billing ? YES. NO ( Look on the Healthcare Menu for more information )
Click to Submit ->