A Medicare Participating Provider

Home Medical Supplies, Inc.
Aurora, CO 80014
Toll Free# (866) 867-3638
Fax # (303)705-1957

To: Dr.______________________________

Phone: __________________


Confirmation of Verbal Order for Glucose Testing Supplies
(Please Sign then Fax to 1-303-705-1957 and Mail Original with Ink Signature)

Medicare requires glucose testing supply prescriptions to be signed and renewed every 12 months. Please complete and sign this form and mail back to HMS Inc.

Patient Name:_______________________________


DOB:___/___/___ SS#:____________ Acct:__________

Prescription: Order Date:_________

Duration of Doctor Order: 1-YR

Please indicate which types of diabetes the above patient is diagnosed with:

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