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Pick-up/UPS Delivery Orders
 

For your convenience on your monthly order, please fill out the following form to have your order ready when you arrive at the specified Carle Medical Supply location. You will NOT be required to pay on-line, but instead we will bill your insurance (if applicable) when you pick up your order. To ensure the accuracy of your order you MUST provide us with the quantity, unit of purchase, record number, product number, and a detailed description for each product. This information is found on a previous invoice or bill. Orders must be received by 3 P.M. to be ready for pick-up or UPS delivery the next business day. Customers are responsible for UPS charges.

We will have your order ready for pickup at any Carle Medical Supply location after 12 P.M. the next business day.

Thank you for choosing Carle Medical Supply!
First Name: MI: Last Name:

Address:

City:State: Zip Code:

E-Mail:

Phone Number:  

Primary Insurance:   
Secondary Insurance:

Delivery Method:
Location to be picked up:

Approximate time of pick up:  Date:      Time:

Quantity Unit Record Number Product Number Description
Comments:
   
* You can also contact Carle Medical Supply by calling (217) 383-3487, or toll free: (800) 851-3373.

 

 


 
Carle Foundation Hospital, Carle Foundation Physician Services and Carle Physician Group contract with insurance providers separately and may or may not choose to participate in all of the same insurance plans. Patients are urged to check with their carriers as to whether services are covered for either or both organizations.

Copyright © 2010 The Carle Foundation

Carle Physician Group Carle Foundation Hospital