Contact Us – Yourhealthandcomfort

QUICK APPLICATION · STEP 1 OF 4

What are you interested in?

QUICK APPLICATION · STEP 2 OF 4

Personal Information

First name *

Last name *

Email address *

Phone number *

If you are filling out this application for someone else, please insert your phone number.

Date of birth *

Gender *

MaleFemale

QUICK APPLICATION · STEP 3 OF 4

Health & Insurance

Do you have Type 1 or Type 2 Diabetes? *

Type 1Type 2I Am Not Diabetic

Do you use Insulin to control your Diabetes?

YesNo

Select Your Primary Insurance *

Please enter your Secondary Insurance

Secondary Insurance Policy Number / ID

If other, please specify your insurance

QUICK APPLICATION · STEP 4 OF 4

Almost done

By clicking either button below, you accept the terms shown here.

I authorize my treating physician and other healthcare providers to share my protected health information (PHI), as defined by HIPAA, with the durable medical equipment (DME) provider supplying my products and with my insurance or payer. This may include medical records, my diagnosis, clinical notes, physician orders, and any other documents needed to process, supply, or obtain payment for my equipment. I understand that I can cancel this authorization at any time by sending a written request, except where it has already been acted on. I also understand that my treatment, payment, enrollment, or eligibility for benefits does not depend on whether I sign this. The DME provider receiving my information is a HIPAA-covered entity and must protect it under the federal and state laws that apply.

I'd like to receive text message updates about my application. I can reply STOP at any time to opt out, or HELP if I have questions. Message frequency may vary, and standard message and data rates may apply.

FULL APPLICATION · STEP 5 OF 7

Home Address

Address *

Address line 2

City / Town *

State *

Zip Code *

Location type

FULL APPLICATION · STEP 6 OF 7

Doctor's Information

The doctor who treats you for diabetes or related conditions.

Doctor's first name *

Doctor's last name *

Doctor's phone number

City

State

FULL APPLICATION · STEP 7 OF 7

Review Your Application

Please confirm your shipping and insurance information below.

Products

Your selected products will appear here

Personal Information

Name, email, phone, date of birth, gender

Health & Insurance

Diabetes type, insulin use, primary insurance

Home Address

Full address and location type

Doctor

Doctor's name, phone, and location

Secondary Insurance

Secondary insurance and policy number

I agree to allow Your Health & Comfort to verify my insurance benefits, obtain medical records and a prescription from my doctor.

If approved by my insurance and physician, I agree to have the products I applied for sent to the above address.

✓

Thank you for your time.

We will contact you shortly.

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Email Address

Call Now

Address

What are you interested in?

Personal Information

Health & Insurance

Almost done

Home Address

Doctor's Information

Review Your Application

Products

Personal Information

Health & Insurance

Home Address

Doctor

Secondary Insurance

Thank you for your time.

Have questions? Get in touch!

Email Address

Call Now

Address

What are you interested in?

Personal Information

Health & Insurance

Almost done

Home Address

Doctor's Information

Review Your Application

Products

Personal Information

Health & Insurance

Home Address

Doctor

Secondary Insurance

Thank you for your time.

Have questions?
Get in touch!