1. ENROLLMENT FORM
Complete the enrollment form and mail to us
- OR -
Call us toll free at (1-800-866-3002) to request and enrollment and consent.
2. PATIENT CONSENT FORM
A Blanket Assignment also known as Consent Form should be completed and mailed to us. The form authorizes us to obtain a prescription from your physician and also allows us to bill Medicare on your behalf.
PATIENT CONSENT FORM
When we have received your signed Patient Consent Form we will contact your physician's office to obtain a prescription for your supplies. We will then contact you to confirm your supply preferences and the date of your first shipment.
No strings attached - No long term commitment: You may cancel or suspend your supply shipments from U S Ostomy Supply at any time.
If you have difficulty filling out the form, or if you would prefer to have an enrollment package sent to you, please do not hesitate to contact us as follows:
Toll Free: (1-800-866-3002)