Apply For Supplies

Patient Application Form

Fill Out Application Online

Click Here for the online application. Please fill out your information. Then press submit.

If you prefer to Mail or Fax the Application to us:

To apply for our services there are two forms that we will need for you to print, complete and mail/fax to us. Please complete both forms:

1. Patient Application Form
2. Medical/Payment Authorization Release

Note: These forms will require Adobe Acrobat. If you do not already have Acrobat Reader please click here to download.

Mail The Forms To Our Address:

Support Plus Medical
904 SE. Prima Vista Blvd., Suite # 200
Port St. Lucie, FL 34952

Or Send Us A Fax:

Fax Number: 866.337.5903

If you are on Medicare, and do not have any supplemental insurance, and believe that the Medicare 20% co-payment would be a great financial hardship, you may apply for our Financial Hardship Assistance Program. Please call one of our associates for details > 800-459-4350.