Become A Customer

Ready to take the next step?

We make it easy on our patients. We will verify their insurance, request the proper paperwork from their doctors, and bill the insurance company. Verification of the insurance ensures patients eligibility, determines the patient’s coverage, what are the patient deductibles, and possible co-pays. We work with most private insurance companies. We will help you find a provider if our company is unable to work with your insurance.

Name

First Name

Last Name

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Insurance Company Name

Insurance Policy Number

Doctor's Name

Doctor's Phone Number

Doctor's Address

Supplies Types

Choose Multiple

Sterile Intermittent Catheters

Gloves

Magic Bullet Suppositories

Underpads

Condom Catheters

Leg Bags

Surgical Lubricant

Jeremiah 33:6

“Behold, I will bring to it health and healing, and I will heal them and reveal to them abundance of prosperity and security.”