Follow these steps to complete your retailer application for the Abbott Diabetes Care Medicare program.
- Download the form. Use the button above to get the PDF version of the application.
- Enter your pharmacy details. Include your business name, address, pharmacy license number, and Medicare or Medicaid supplier ID.
- Read the program terms. Review all conditions set by Abbott Diabetes Care Sales Corporation before signing.
- Sign the application. An authorized pharmacy representative must sign and date the Retailer Application section.
- Submit to your wholesaler. Send the completed form to ANDA Inc. or your designated Abbott Diabetes Care wholesaler as directed.
Keep a copy of the submitted form for your pharmacy records. Contact Abbott Diabetes Care for status updates on your application. Related forms: Blood Glucose Log, Diabetes Foot Exam Form, Blood Glucose Monitoring Form.