Enrollment

Easy Enrollment Form

Signing up for the IDS Care program is easy! Just fill in the form below and we'll take care of everything! This form is submitted through 128 Bit Encryption, so your information is kept safe with us. You can verify security by the "Golden Lock" along the bottom of your browser. See our security or privacy policy if you have any concerns. Please Allow 7 to 10 business days to receive your initial order.
 
Required Information
Name: Medicare Number:
Phone: Birthdate:
Evening Phone If you are not there when we call, can we leave a message that IDS called? Yes  No
Time:
Email:
Insurance Information
Company: City:
State: Phone:
Insured: ID#:
Group#: Employer:
Optional Information
Address: City:
State: ZIP Code:
Diagnosis: Allergies:

Doctor's Information
Doctor's Name Doctor's Phone Number
I Need: (Check all that apply)
Prescription Medications Glucose Test Strips
Lancets Syringes or Accessories
Glucose Meters Other:
I authorize a IDS Care representative to contact me.
Please type "yes" to authorize.