By joining Diabetic Support Program; I agree to, understand and authorize the following:

A. Assignment of my insurance benefits to the Diabetic Support Program for products, equipment or medications furnished to me by the Diabetic Support Program.

B. Diabetic Support Program to directly submit claims on my behalf to my insurance company for products, equipment or medications furnished to me by Diabetic Support Program.

C. Diabetic Support Program to request, obtain and use my medical or other information as required, to verify medical necessity and process my order for products, equipment or medications, determine my insurance eligibility, coverage and benefits, submit claims for payment and/or respond to insurer inquiries.

D. Diabetic Support Program to release information in their files to their contracted agents, my physician(s), caregiver(s), Medicare, Medicaid, Medicare Supplemental, Employer Sponsored or any other insurers and/or their agents or assigns for purposes of managing my account. Diabetic Support Program will never sell, release or provide your personal information to anyone other than as specified.

E. Diabetic Support Program and their agents or assigns to contact me by telephone, regular mail, Email or facsimile regarding my account and order(s) for medical products, equipment or medications and to offer or discuss other products and services that Diabetic Support Program provides.

F. To pay all amounts owed by me that are not covered by my insurer(s) and for which I am responsible according to my insurance/benefit plan’s participation criteria.