Become a Member

Home / Become a Member

Please complete this interactive form to get your account started. Once submitted, one of our Customer Service specialists will be in contact with you soon.

Patient Information

* First Name:

* Last Name:

Fill this out:

* Date of Birth:

* Gender:

Parent/Guardian/Responsible Party

* First Name:

* Last Name:

* Date of Birth:

* Gender:

Billing/Contact Address

* Primary Phone:

Alternate Phone:

* E-mail:

* Street Address:

Apt/Bldg/Ste:

* City:

* State:

* Zip:

* County:

* Use same address for shipping?:

Yes

Shipping Address

* Street Address:

Apt/Bldg/Ste:

* City:

* State:

* Zip:

Caregiver

* Does the patient have a caregiver?:

Yes

* First Name:

* Last Name:

* Primary Phone:

Alternate Phone:

E-mail:

Agency / Relationship:

Prescribing Physician

* Physician Name:

* Physician Phone:

* City:

Insurance

* Do you have insurance?:

Yes

* Name of Insurance:

Please Specify:

* Member ID/Contract #:

Group #:

* Are you the Subscriber or Policy Holder?:

Yes

Subscriber Information

* First Name:

* Last Name:

* Date of Birth:

* Gender:

* Relationship to Member (the member is my…):

* Primary Phone:

Alternate Phone:

* Use billing/contact address?:

Yes

Subscriber Address

* Street Address:

Apt/Bldg/Ste:

* City:

* State:

* Zip:

Do you have additional health insurance?:

Yes

* Name of Insurance:

Please Specify:

* Member ID/Contract #:

Group #:

* Are you the Subscriber or Policy Holder?:

Yes

Subscriber Information

* First Name:

* Last Name:

* Date of Birth:

* Gender:

* Relationship to Member (the member is my…):

* Primary Phone:

Alternate Phone:

* Use billing/contact address?:

Yes

Subscriber Address

* Street Address:

Apt/Bldg/Ste:

* City:

* State:

* Zip:

Condition Questions

* How many months/years since diagnosis?:

* Have you been trained to use the supplies you are requesting?:

Yes

* Who was training done with?:

Do you feel properly trained?:

Yes

* Are you currently pregnant?:

Yes

Due Date:

Is your diagnosis Gestational Diabetes?:

Yes

Will you only be needing supplies for the duration of your pregnancy?:

Yes

* Are you treated with Insulin? (Injections or Insulin Pump):

Yes

* Has the member ever owned or used an insulin pump?:

Yes

* Is the member currently using a pump?:

Yes

* Current Brand/Model:

Please Specify:

* Date pump was received:

* Serial #:

On the back of your device, look for the letters "SN" (which stands for serial number). Your serial number will be a series of numbers and/or letters after the "SN".

* Out of warranty date: Out of warranty information can be obtained by calling the manufacturer of your insulin pump (their number is typically listed on the back of your insulin pump).

* Is a new pump needed?:

Yes

* Would you like J&B to service your new pump?:

Yes

Why?:

Where will you be getting the pump from?:

* Brand/Model:

Please Specify:

* Why is a new pump needed?:

* Have you discussed the need for a pump with your physician?:

Yes

* Would you like J&B to service your pump supplies?:

Yes

Why?:

Where will you be getting these supplies from?:

* Infusion Set Product Code: On your product packaging, look for the letters "REF" (which stands for reference number). Your reference number will be a series of numbers and/or letters after the "REF".

* Reservoir / Cartridge Product Code: On your product packaging, look for the letters "REF" (which stands for reference number). Your reference number will be a series of numbers and/or letters after the "REF".

* How often is the site changed?:

* Date last order was received?:

Was your last order of testing supplies a 30 or 90 day order?:

30 days

90 days

* Would you like J&B to service your syringes and/or pen needle tips?:

Yes

Why?:

Where will you be getting these supplies from?:

* Syringes:

* How many used per day?:

* Would you like J&B to service Alcohol Wipes?:

Yes

* Pen needle tips:

* How many used per day?:

* Date last order was received?:

Was your last order of injectables a 30 or 90 day order?:

30 days

90 days

* Would you like J&B to service your Meter, Test Strips, Lancets and Control Solution?:

Yes

* Select brand of supplies:

Please Specify:

* Do you need a new meter?:

Yes

* Testing times (Per Day)?:

* Select Lancets:

Please Specify:

* Date last order was received?:

Was your last order of testing supplies a 30 or 90 day order?:

30 days

90 days

Why?:

Where will you be getting these supplies from?:

* Would you like J&B to service your Ketone strips?:

Yes

* Blood: How many used per day?:

* Urine: How many used per day?:

* Date last order was received?:

Was your last order of testing supplies a 30 or 90 day order?:

30 days

90 days

Why?:

Where will you be getting these supplies from?:

CGM Supplies

* Has the member ever owned or used a CGM?:

Yes

* Would you like J&B to service your new CGM?:

Yes

* Are you currently using a CGM?:

Yes

* Brand/Model:

Please Specify:

* Brand/Model:

Please Specify:

* Would you like J&B to service your CGM Supplies?:

Yes

CGM Transmitter

* Date Transmitter was received:

* Serial #:

* Out of warranty date: This information can be obtained by calling the manufacturer's number on the device.

* Is a new Transmitter needed?:

Yes

* Brand/Model:

Please Specify:

CGM Receiver

* Date receiver was received:

* Serial #:

* Out of warranty date: This information can be obtained by calling the manufacturer's number on the device.

* Is a new Receiver needed?:

Yes

* Brand/Model:

Please Specify:

* Are sensors needed?:

Yes

* Sensor Product Code:

* Date last order was received?:

Lasted for:

30 days

90 days

Breast Pumps

* Brand/Model:

Referred by:

* Has baby been delivered? :

Yes

* Delivery Date :

* Estimated Due Date :

* Have you received a breast pump through your insurance before?:

Yes

* When did you receive your last breast pump? :

* Have you spoken to another supplier about your need for a breast pump?:

Yes

Name of Supplier:

* Have you cancelled your request with that supplier?:

Yes

Ready to continue?