Crystal Home HealthCare

All diabetics on Medicare with a supplemental policy qualify for FREE diabetes testing supplies provided you have met all applicable deductibles. Medicare will pay 80% after you have met your annual $100 Part B deductible, and your supplement should cover the remaining 20%. If you do not have supplemental coverage, we will simply bill you for the remaining co-insurance and/or deductible at a later date.

We ship without advance payment and send the bill directly to Medicare for all diabetics.

We can provide as many test strips and lancets as are medically necessary (typically 100 per month (300/quarter) for those taking insulin shots, 100 for three months for non-insulin dependent), a lancing device once a year, control solution, batteries, and a new meter if you need one. Please note, if you test more frequently per your doctor's orders, please send us a copy of your log book showing one full month of daily blood test results. We are required by Medicare to keep a record on file so we can ship the full amount you need. There is no cost to join and we provide FREE delivery nationwide.

To enroll and begin receiving your supplies conveniently delivered to your door, please complete the following form and "Submit" it via the button at the bottom of the page.
FYI: This form sends a simple e-mail message instantaneously to our account. Though transmission may not be secure, the likelihood of a third party intercepting any private information while it is enroute is statistically negligible. Once received in our account, your information is safe. If you are not comfortable with this level of security, please call us at 1-800-493-4902 with your information or print and fax/mail this form to us. Thanks.

PATIENT DATA
Name:
Address 1:
Address 2:
City:	State: Zip:
Day Phone:	Evening Phone:
Date of Birth:	Soc Sec #:
Email Address:
Next of Kin Name:

MEDICARE NUMBER

I take insulin shots to control my diabetes
I take oral medication to control my diabetes
I test my blood times per day.

PHYSICIAN DATA
Name, Address, Phone

SECONDARY INSURANCE INFORMATION
Company, Address, Phone, Group Number, Certificate Number

Please send me the following test strips:
	# of Strips:

Please send me the following lancets:
	# of Lancets:

Please send me the following meter:

Please send me the following lancing device:

Please send me the following control solution:
	#:

Please send me the following meter batteries:
	My meter uses #:

STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDER
I request that payment of authorized medicare benefits be made on my behalt to Crystal Home HealthCare for any services furnished me by CHHC. I authorize any holder of medical information about me to release to the Health Care Financiang Administration and its agents any information needed to determine these benefits.
Yes, I agree

I heard about this program through

Additional Information, Questions, Comments, or Instructions:

Thank you for your order. We ship by UPS Ground in most cases and US Mail in others. Please allow one week for your first order. Medicare requires us to obtain written authorization from your physician. If you experience problems with this form, please call 1-800-493-4902, simply e-mail us, or print and mail/fax to CHHC-Free Program, P.O. Box 19457, Detroit, MI 48219-9981. FAX: (313) 493-4904. Medicare will pay 80% and your supplemental insurance will cover the remaining 20%. If you do not have supplemental coverage, we will simply bill you for the remaining co-insurance and/or deductible at a later date.