MegaShop
1-800-746-7505
0 items - $0.00

Cart

Categories

  • All Medical Alert IDs
  • Brands
    • Abbott
    • Accu-Chek
    • ARDO USA
    • BD Products
    • FIFTY 50 Medical
    • Kendall
    • Medicool
    • Medtronic
    • Owen Mumford
    • Smith & Nephew
    • Valeant Pharmaceuticals
  • Breast Pumps & Nursing Aids
    • Nursing Aids
  • Diabetes Supply Cases
  • Dietary Aids
  • Kid's Corner
    • Bracelets
    • Educational Products
    • Meter Skins
    • Necklaces
    • Pain Relief
    • Supply Cases
  • Lancets & Devices
  • Miscellaneous
  • Needles & Syringes
    • Injectors
    • Needles
    • Syringes
  • PPE
    • Masks
    • Thermometers
  • Pump Supplies
  • Skin Care & Prep
  • Specials
  • Test Strips/Control Solution

Menu

Skip to content
  • Home
  • Brands
  • Specials
  • All Medical Alert IDs
  • Insurance
    • Online Insurance Form
    • Patient Credit Card Information
  • Kid’s Corner
  • Miscellaneous
  • Diabetes Supply Cases
  • Resources
    • Customer Support
    • Shipping Rates and Policies
    • Common Questions
    • Return Policy
    • Downloads – Software
  • Dietary Aids
  • Lancets & Devices
  • Needles & Syringes
  • Pump Supplies
  • Test Strips/Control Solution
  • Ask the Pharmacist
  • Skin Care & Prep
  • Customer Service
    • My Account
  • PPE

Insurance Form

  • Thank you for your interest in registering with FIFTY 50 Pharmacy.

    Because we participate in nearly every insurance plan in the country, and are considered a major medical and pharmacy provider in these networks, we often save our patients money by helping them better understand their coverage. You see, we’ll check on your benefits and see which offers you the best deal. Regular retail pharmacies can’t/won’t take the time to do this, but it’s just another service we provide our customers at no additional charge.

    By completing this form, you’ll be providing us with the information we need to help make this evaluation. We’ll only use this information to help with your insurance benefits, and we’ll never share it with anyone.

    Completing this information doesn’t obligate you to use us in any way. It just allows us to get you set up in our computer system so if you do choose to buy your supplies from us, you’ll be ready to go when you need them. We look forward to serving you!

    *=Required
  • PATIENT INFORMATION

  • Please enter a number less than or equal to 24.
  • DOCTOR INFORMATION

  • POLICY HOLDER INFORMATION

  • INSURANCE COMPANY

  • PRESCRIPTION INFORMATION

  • MEDICARE INFORMATION

  • SUPPLEMENTAL CARRIER INFORMATION

  • PAYMENT FOR SERVICES NOTICE

  • In accordance with the receipt of services provided by Fifty50 Medical, I hereby agree that my insurance benefits be paid directly to Fifty50 Medical. In addition, I agree to cooperate fully to secure such payment and I authorize the release of information required to file an insurance claim on my behalf from the prescribing physician, hospital and to the insurance carrier. In the event my insurance refuses reimbursement, I agree to be personally liable for all pharmacy charges incurred. I also understand FIFTY 50 Medical requires a credit card on file for insurance copay and charges. My credit card information has been provided. I have read and I understand all of the above.
  • Enter your name.
  • SSL Certificate by Comodo
  • HIPAA Agreement

  • THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY.

    The Privacy Act is in place in order to protect patient's medical records and other health information provided to health plans, doctors, hospitals, and other healthcare providers and took effect on April 14, 2003. Developed by the Department of Health and Human Services (HHS), these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed. They represent a uniform, federal floor of privacy protections for consumers.

    Congress called on HHS to issue patient privacy protections as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA included provisions designed to encourage electronic transactions and also required new safeguards to protect the security and confidentiality of health information. This covers us as a healthcare provider who conducts certain financial and administrative transactions (i.e. enrollment, billing, eligibility information, etc.) electronically.

    This policy ensures privacy protections for patients by limiting the ways that health plans, pharmacies, doctors, hospitals and other covered entities can use patients' personal medical information, whether it is on paper, in computers, or communicated orally.

    Fifty 50 Medical may use your personal medical information for the following reasons:

    FOR TREATMENT: We may use medical information about you to provide you with medical supplies. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you.

    FOR PAYMENT: We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on, or accompanying the bill may include your medical information.

    ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment and/or payment, we may use and disclose medical information for the following purposes:

    In our facility: Unless you notify us that you object; your needed medical information, name, address, phone numbers, insurance information, date of birth, payment information, and/or social security information will be stored in our systems. As well as any other personal information that you have informed us of.

    Notification: We may use and disclose medical information to notify or help notify: your guardian, family members, doctors, nurses, or other persons responsible for your care. As always, we will also use our best professional judgment to make decisions in your best interest about allowing someone to pick up medication, medical supplies, or medical information for you.

    Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities responsible for preventing or controlling disease, injury, disability, child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration (FDA) for purposes of reporting adverse events associated with product defects or problems.

    Alternative and Additional Services: We may use and disclose medical information to furnish you with information about health-related benefits, and services that may be of interest to you, and/or send you catalogues, postcards, or flyers containing condition related product advertisements.

    In accordance with the receipt of services provided by Fifty50 Medical, I hereby agree that my insurance benefits be paid directly to Fifty50 Medical. In addition, I agree to cooperate fully to secure such payment and I authorize the release of information required to file an insurance claim on my behalf from the prescribing physician, hospital and to the insurance carrier. In the event my insurance refuses reimbursement, I agree to be personally liable for all pharmacy charges incurred. I also understand FIFTY 50 Medical requires a credit card on file for insurance copay and charges. This can be given at checkout. I have read and I understand all of the above.

  • This field is for validation purposes and should be left unchanged.

Sign Up For Newsletter

Diabetic Supplies

FIFTY 50 Medical, a leader in diabetes supply products like ONE TOUCH Ultra strips, insulin pump supplies and blood glucose monitors, diabetic medical id bracelets, meters, insulin pump supplies, meter skins, test strips and discount diabetes supplies from FIFTY 50 Medical your online diabetes store.
  • Home
  • Brands
  • Specials
  • All Medical Alert IDs
  • Insurance
  • Kid’s Corner
  • Miscellaneous
  • Diabetes Supply Cases
  • Resources
  • Dietary Aids
  • Lancets & Devices
  • Needles & Syringes
  • Pump Supplies
  • Test Strips/Control Solution
  • Ask the Pharmacist
  • Skin Care & Prep
  • Customer Service
  • PPE
© 2023 www.fifty50pharmacy.com. All Rights Reserved.
SSL Certificate by Comodo