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Managed Care and Employer Group Plans

Latino Diabetes Program

Frequently Asked Questions and Resources

It's time to re-order your supplies! Please, complete the form below to receive your new order Or call us at (407) 331-6423 or toll-free at (800) 981-2495

* Required Fields

*First:

*Last:

*Phone:

Secondary Phone:

*Email:

*Address:

*City:

*State/Province:

*Zip /Postal Code:

Patient Account Number:

If your insurance has changed since your last re-order
please note those changes in the box below.

PLEASE SELECT THE ITEMS YOU NEED

I’m interested in finding out if I’m eligible for a FREE Meter Upgrade – please call me!

How often do you check your blood sugars (glucose)?

Meter test strips:

Please select the strips for the meter you are currently using

	Contour	Contour TS
	Easy Check	Easy Step
	Prodigy	Element
	Other
Other items:

Lancets

Lancing device

Control solution

Batteries

I’m interested in having all my medications delivered to my home – please call me!

Authorization of Benefit (AOB) – by submitting this form I authorize Total Health Diabetes, "THD", and/or any of their corporate affiliates to contact my physician to obtain a prescription, contact my insurance company to verify my benefits and contact me to discuss my order and authorize the release of my medical information to process and submit claims to my insurer(s) and for THD to receive payments for products authorized and received by me. I certify that THD provided me copies of the Patient Rights & Responsibilities, Protocol for Resolving Complaints and Reporting Fraud, Equipment Warranty Information, Returns and Refunds Policy, THD Notice of Privacy Practices, CMS Medicare DMEPOS Supplier Standards, Home Safety Information and Weather Emergency Information.