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Diabetics

Must be a diagnosed diabetic to submit this form.  Upon completing submission, the free supplies can take up to two weeks to be active.  We recommend calling the pharmacy to confirm the supplies are free if trying to pick up before two weeks.


Diabetes Questionnaire

• Employees - Enter only your ID# without the letters
   Example: 54321
• Spouses - Enter the employee's ID# followed by sp
   Example: 54321sp
I am... (choose one):

By selecting "Yes" below, I confirm I am a diagnosed diabetic. :
If you are NOT a diagnosed diabetic, please do not complete this questionnaire.
If yes, and your A1C is under 7.5 – are you interested in the Free Supply Program?:

If yes, and your A1C is greater than 7.6 – are you interested in working with MTM to participate in our Free Supply Program?:


NOTE: If your A1C is above 7.5 and you select "no" to working with MTM, you WILL NOT get free supplies
If you are NOT interested in working with MTM, please enter N/A in the field above.
Have you participated in the free supply program before?:

 

 
After clicking the submit button below, please make sure there are no error messages and wait for the confirmation message to display.
 

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