Register | Pain Management Technologies,Products,Services

Registration Form

We highly value your privacy. All your information is strictly confidential.

Contact / Shipping Information

Please tell us where you would like us to send your supplies.

Name

First

Last

Address

Street

Suite/ Apt.

City

State

Zip/Postal

Home Phone

- -

Alternate Phone

- - (optional)

Fax

- - (optional)

Email Address

How did you hear about us?

Primary Insurance Information

(optional - to verify your eligibility for diabetic supplies )

Health Plan Name

Enter health plan name exactly as it appears on your health insurance card.

Medicare / Policy Number

Enter policy number exactly as it appears on your health insurance card.

Group Number

Enter if applicable. (Not necessary for Medicare.)

Phone Number

- -

This can be found at the back of your insurance card

Relationship to Policy Holder

Select "Self" if you are the insurance policy holder.


	First		Last

Secondary Insurance Information

(optional - to verify your eligibility for diabetic supplies )

Health Plan Name

Enter health plan name exactly as it appears on your health insurance card.

Medicare / Policy Number

Enter policy number exactly as it appears on your health insurance card. Include the letter that follows your soc. sec. number.

Group Number

Enter if applicable. (Not necessary for Medicare.)

Phone Number

- -

This can be found at the back of your insurance card

Relationship to Policy Holder

Select "Self" if you are the insurance policy holder.


	First		Last

Medical Information

(optional - to contact your doctor for a prescription for diabetic supplies)

Physician's Name
		First	Last

Physician's Phone

- -

Number of times per day that you test your blood glucose level

Number of times per day that you inject insulin, if applicable

Name of blood glucose meter that you currently use

Did your insurance cover your present meter?

Are you interested in a new meter?

Date of Birth

/ /

Gender

Can you get doctor to fill out our form Rx?

If so, download our form here PDF attachment here

If not, we will obtain from your doctor.

AutoShip

(optional)
AutoShip :		Yes No
Choose Autoship if you would like to receive your diabetes testing supplies automatically. Your supplies will be shipped every 90 day. We will contact your Doctor for a valid prescription and send you only those supplies ordered by your Doctor. We will bill your insurance plan(s) and charge your credit card for the deductible and/or co-insurance amount, if any.

Due to Medicare laws, AutoShip is only available to private insurance customers.

Mail To: info@pmtmedical.com Phone: 800-239-7880

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