Last Name*:		First Name*:
Address*:
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City*:
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Phone Number*:		Cell Phone:
Date of Birth:		Gender:	Male Female

Are you Insured?:
Insured
Uninsured
If you are insured, which insurance you have?:
Medicare
Medicaid
Private Insurance
Not Sure
Which of the followings may apply to you?:
1. You have Diabetes and use a glucose meter to test your blood sugar daily
2. You would like free information about a scooter or power chair for yourself or a loved one
3. You have sleep apnea and your doctor has suggested you use a C-PAP device while you sleep
4. You have urinary problems that require you to use single-use disposable catheters
5. You are living with back pain and would like free information about a back brace
6. You are living with arthritis and would like free information about a heating pad

公司声明是，Optimal HealthCare USA LLC (美国佳康有限公司)不是医疗保险公司，也不是政府机构，是全心全意为我们自己华人朋友服务的公司。我们的专业工作人员会为每一位申请人全方面、全力做申请的所有准备工作，督促、掌握、协调申请处理进度及情况，并及时反馈给申请人。但公司对申请的结果不具有决策权。一般来说，自申请到收到第一次药品大约需要五周时间。另外，对申请人身份限为 绿卡或公民，是药品生产厂家的要求，而不是本公司对申请人身份的限制。特此申明！

请拔打电话 1-888-817-1618

(东部时间周日9：00AM－5：00PM， 其它时间请留言）

P.O. Box 292467, Fort Lauderdale, FL 33329

© Optimal Healthcare USA LLC 2012