Tulsa

OKLAHOMA  CITY

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Insulin Pump Supplies

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Insulin Pump Supplies

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MM/DD/YYYY
Are You Still Using Your Equipment Associated With Items You Are Requesting ? (if no, you may not eligible for related supplies)
What Items Are You Needing? Products will be based on what was previously ordered or by physician’s order, unless specified.
— OR — (select all items that apply)

Towards each requested supply item, please list the quantities remaining. *Question is only required for patient’s who have  Medicare, Medicare Advantage or Medicaid*

Has your health insurance, ordering physician, physical address or ordered supplies changed since your last order? (If Yes, we will call you to get the updated information)
Would You Like Us To Call You To Discuss Your Current Therapy?
By checking this box, you the patient authorize payment(s) to be released from Medicare, Medicaid, or any other insurance benefits on your behalf to Madison Medical for services/products rendered to you. Required to bill insurance.
Notice: This is an order request. Orders may not be completed if no current medical order is on-file, insurance ineligibility, overdue balance on account or a customer service representative needs to make contact with you prior to shipping. If you are not enrolled in AUTO PAY, a customer service representative will be reaching out to you, prior to shipping, if your out-of-pocket expense is greater than $75. Shipping charges may apply. Remember to Register for Patient Portal Access (View & Pay Invoices, Setup AUTO PAY and eDelivery) See link on our home page.

*Remember to Register for Patient Portal Access (View & Pay Invoices, Setup AUTO PAY and eDelivery) See link on our home page.*

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