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New user registration form
(selected provider: Life Care Supplies)
Your information
First Name *
required
Middle Name
Last Name *
required
Date of birth *
required
not a date
(optional) SSN
Gender *
Female
Male
required
Phone number *
required
Email Address *
required
not an email
Address *
required
Suite/Apt. #
City *
required
State *
required
Zip code *
required
Upload Rx Image (optional)
Remove
Receive Email
(refill reminders, shipping and delivery information only)
Receive refill reminders by phone
Same as your information
(optional) Insurance subscriber information
Name
Phone number
Address
Suite/Apt. #
City
State
Zip code
(optional) Primary insurance information
Insurance name
Member number
Subscriber number
(if different)
Insurance phone #
Address
City
State
Zip code
No secondary insurance
(optional) Secondary insurance information
Insurance name
Member number
Subscriber number
(if different)
Insurance phone #
Address
City
State
Zip code
(optional) Physician information
Physician name
NPI number
Physician phone #
Address
City
State
Zip code
HME Relay
4305 Pineview Dr
Walled lake MI 48390
USA
support@hmerelay.com
877-527-4633
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