Diabetes Supplies Health Insurance Coverage Inquiry Form

J & B Medical’s insurance team can help find out if your supplies are covered by your medical insurance. Fill out the form below and a J & B representative will contact you within one business day to assist you!

You can also call us toll free at 800-737-0045, option 1.

Please provide complete information to ensure fast service. (*Indicates a required field).

 

Patient Information

First name: *
Last name: *
Address: *
City: *
State: State... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *
ZIP Code: *
Daytime Phone:
Alt phone:
Email address: *
Date of birth:

Insurance Information

Primary Insurance Name: *
Insurance Contract/ID number: *
Secondary Insurance Name:
Insurance Contract/ID number:

Caregiver Information

Caregiver Name:
Caregiver Phone Number:

Products Needed

Diabetic Supplies
Ostomy Supplies
Urological Supplies
Incontinence Supplies
Other: