Mail Order Diabetic Supplies Home Delivery Program from SHOPMASH.com

The SHOPMASH.com Mail Order Diabetic Supplies Program is a specialized mail-order service which provides a convenient way to order your diabetic supplies for families and individuals with Medicare and/or Private Insurance coverage. Our Starter Kits includes everything you'll need to start checking your blood sugar levels and get on your way to better health.

How the program works: Your diabetic testing supplies may be reimbursed by Medicare and/or Private Insurance coverage. When you order from SHOPMASH.com, your order will be shipped the next business day and usually arrives at your doorstep within 48 hours via UPS Ground. Then, we will bill your insurance and any supplemental insurance on your behalf. It's Simple.

That's right, no traveling or waiting in line at the pharmacy for your diabetic supplies, ever again. Always remember to check your blood sugar levels as directed by your doctor and let SHOPMASH.com help you live a healthy life. Once you've started using our service, you'll be glad you did.

FreeStyle/FreeStyle Flash Starter Kit (Includes: Freestyle Glucose Meter, Carrying Case, Instructions, Control Solution, Lancets Device. Testing Strips and Lancets for a 90 Day Supply)

OneTouch Ultra Starter Kit (Includes: OneTouch Ultra Glucose Meter, Carrying Case, Instructions, Control Solution, Lancets Device. Testing Strips and Lancets for a 90 Day Supply)

Prestige Starter Kit (Includes: Prestige Smart Meter, Carrying Case, Instructions, Control Solution, Lancets Device. Testing Strips and Lancets for a 90 Day Supply)

Sign-up Take a moment to sign up for the SHOPMASH.com Mail Order Diabetic Supplies Program. Complete the necessary form to get started today on the road to better health. We will begin processing your order the same day. Please fill out the form completely, missing information will delay your order. We will review your information and contact your physician and insurance provider to obtain additional information.

Note: If your insurance provider is a HMO please call (800)768-9182 for coverage verification.

		Patient Registration

First Name:	Middle Name:	Last Name:

Referred By:

Referral Company Name (HME Providers Only)

Email Address:

Address:

City:	State:	ZIP:

Home Phone:	Work Phone:	Fax:

Date of Birth:	Social Security Number:

	Height:	Weight:
Gender:

Marital Status:

Employment:

		Medical Information

Primary Insurance Company

ID #:	Group #:

Insured Person:	Relationship:

Secondary Insurance Company

ID #:	Group #:

Insured Person:	Relationship:

Name of Doctor:

Address of Doctor:

City / State and Zipcode of Doctor:

Doctor Phone:	Doctor Fax: (Needed to process order)

By completing this form, you are authorizing a SHOPMASH.com representative to contact you.