Liberator Medical Supply - Secure Insurance Form

Liberator Medical Supply - Home Care Medical Products

In order for us to provide you with insurance billing services, we need for you to provide the following information for our files.

Any information that you disclose to us is subject to our Privacy Policy and will not be shared with any 3rd parties.

Enter your personal information.

First Name	MI	Last Name

Street Address 1	Street Address 2

City	State	Zip Code


Social Security Number
- -

Email Address	Gender	Date of Birth


Phone Number	When is the best time to call you?
- -
Alternate Phone Number
- -

Enter your physician's information.

We will contact your physician for you to obtain a valid prescription for your supplies.

Physician's Name	Physician's Phone
	- -

Enter your Medicare or private insurance information.

We'll provide a free insurance verification for your medical supply coverage.

My Insurance is:






	- -

Help us to help you by answering a few simple questions.

Do You use diabetic testing supplies?

Do you use a catheter?

Do you use mastectomy products?

Do you use ostomy supplies?

Enter any other information or questions here:

Be sure to complete the AOB Form
Only by completing and signing the Assignment of Benefits (AOB) form can we do all your paperwork for you and bill Medicare or your insurance company for all your medical supplies.
Click to print off the Assignment of Benefits (AOB) Form

By clicking submit, you are authorizing Liberator Medical Supply to contact you by telephone and email.