A Medicare Participating Provider
Medical Supplies, Inc.
Aurora, CO 80014
Toll Free# (866) 867-3638
Fax # (303)705-1957
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.
DOB:___/___/___ SS#:____________ Acct:__________
Prescription: Order Date:_________
Duration of Doctor Order: 1-YR
indicate which types of diabetes the above patient is diagnosed with: