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New user registration form   (selected provider: Life Care Supplies)
Your information
First Name *   
Middle Name
Last Name *   
Date of birth *     
(optional) SSN
Gender *    
Phone number *   
Email Address *       
Address *   
Suite/Apt. #
City *   
State *   
Zip code *   
Upload Rx Image (optional)    
  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
 
Security check.     
   
       
 
HME Relay
4305 Pineview Dr
Walled lake MI 48390
USA
877-527-4633
© HME Relay 2020