Email Client Insurance Form

If you have difficulty filling out the form, or if you would prefer to have an enrollment package sent to you, please do not hesitate to contact us as follows: Client Services 1-866-586-6154 or Email Client Support

BILL MY INSURANCE

BILL MY INSURANCE

To determine if we can bill your Health insurance for your medical needs, please complete the following form. We will contact you after the form is received and your coverage is verified. Please remember that we have secured the transmission (via SSL) of all data through our site, so your sensitive Client information will be safe. Contact us directly at 1-866-586-6154, for more information. Should you Prefer a client package to be mailed, please let us know in the comments field. IN ORDER TO BILL YOUR INSURANCE WE WILL NEED A VAILD PRESCRIPTION, WE WILL CONTACT YOU FOR THIS. We Are a Medicare, Blue Cross and Aetna Preferred Providers and accept assignment on most products

* First Name

* Last Name

* Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

Cell Number

* Email Address

Date of Birth

* Gender

Primary Insurance

Primary Insurance Policy #

Insurance Phone #

Secondary Insurance

Secondary Insurance Policy #

Insurance Phone #

We ship Medical Products and Supplies anywhere in the USA. We take assignment on CPAP Supplies, Urological and most Medical Equipment & Supplies.

Type Of Supplies or Equipment (If Known)

Equipment or Supply

Comment's Special Requirments, Please List Below

* Indicates Response Required


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In this website, we have tried to offer the most popular medical equipment & medical supply products, such as portable oxygen concentrators, wound care dressings, CPAP supplies and much more at very competitive pricing.

Should you require an item not listed, or if your needs are specialized, please contact our Medical Department Store sales staff at 1-800-741-1762. Our experts are here to help you. Shop the Medical Department Store and Save!

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