Fit4D Services for Patients with Medicare

Congratulations! Medicare will cover you for telehealth services when prescribed for medical nutritional therapy for diabetes. 80% of the cost is covered, and you are responsible for the 20% balance and your copay amount.

To get started, please download and complete the following two forms and send them to us via fax (xxx-xxx-xxxx) or email (info@fit4d.com).

HIPPA FORM

1500 CLAIM FORM

(Note: you need a PDF reader in order to access these forms. Click here to download Adobe Reader and click here to download Foxit Reader)

Please also provide the following information:

First Name*

Last Name*

Email*

Name of physician who is prescribing medical nutrition therapy for diabetes*

Phone number of physician*

[checkbox] Yes, you have permission to contact my physician.

[submit]