Insurance Billing

Diabetic Testing Supplies by Mail

Print this form.  Complete and sign at bottom.  And mail this form to:
John's Pharmacy
2001 Independence
Cape Girardeau, Missouri 63703-5800
---------------------------------------------------------------------------------------------------

 By my signature below, I request that payment of authorized insurance benefits be made on my behalf to John's Pharmacy for any services furnished to me by John's Pharmacy.

I authorize any holder of medical information about me released to Medicare and its agents if needed to determine these benefits or the benefits payable for related services.

In addition, I agree to be responsible for the supplies billed to Medicare or my other insurance company (as listed on the Request for Patient Information), if John's Pharmacy is not reimbursed.

Patient's Signature:_________________________________________________

Date Signed:_____________________________