Delivery is always included for Medicare patients

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Customer Application Please complete the form below to have your Diabetic Supplies, Catheters, or Lower Back (Lumbar) Relief provided to you at little or no cost to you*.
We will deliver right to your home or office, and bill Medicare or your insurance. Our most common acceptable insurance plans are listed below.
Please call (877) 937-8342 if you have any questions, or to provide the information over the phone.

We Typically Accept:
Medicare Medicare Advantage (Medicare Replacement) AARP Advantra Freedom Aetna Medicare Open PFFS Atrio BlueCross and BlueShield (BCBS) Care Improvement Plus Galaxy HealthNet Pearl Humana GoldChoice SecureHorizons	SelectHealth University Health Care (University of Utah) OPPN Ohio Preferred Provider Network Sierra Sterling Tricare Today's Option UniCare Life and Health Insurance Company University Health Care Insurance Company Utah Medicaid (except Molina)

* Required field

Patient Information
First Name:	*
Last Name:	*
Address:	*
Address 2:
City:	*
State:	*
Zip Code:	*
Home Phone:	*
Alternate Phone:
Date of Birth:	*
Email:	*

Insurance Information
Insurance Plan:	*
Insurance ID Number:	*
Insurance Phone Number (if not medicare):

Physician Information
Physician Name:	*
Physician Phone:	*
Physician Fax:

I'm interested in: (check boxes that apply)

Diabetes Testing Supplies
Insulin Pump Supplies/Syringes
Intermittent Urinary Catheters
Lower Back Pain Relief
Other (specify)

Additional Comments:

By submitting this form, I authorize Western Diabetic Supplies to contact me and my physician regarding the provision of supplies. This information is to be used only for this purpose.

* deductibles and co-insurance may apply

This site is for informational purposes only and is not intended as a substitute for advice from your own physician or other health professional. You should not use the information contained on this site for diagnosing or treating a health problem or disease, or prescribing any medication. You should read carefully all product packaging. You should consult with a healthcare professional before starting any diet, exercise or supplementation program, before taking any medication, or if you have or suspect you might have a health problem. Information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease. Prices and promotions are subject to change without notice.