Jeremy Gomez
 
 
  
 27 Nov 2020 14:35 FROM- 
 CWFMD 
 936-703-5455 
 T-242 P0066/0075 F-228 
 19 Jan 2020 10:59:26 
 2 
 /3 
 Walgreens 
 PLEASE INITIAL AND DATE ALL CHANGES 
 Diabetic Detailed Written Order 
 Fax form with prescriber's signature & date to 1-866-855-5888 (toll free fax) 
 1. Date of Order: 11 May 2014 
 2. Patient Name: Jeremy Gomez 
 Address: 14570 TRERO LN 
 City: WILLIS 
 State: TX 
 Zip: 77378-4394 
 Gender: FEMALE 
 Birth Date: 10 Oct 1987 
 3. Primary ICD-10 Diabetes Diagnosis: 
 R73,9 
 Diabetic Type: 
 4. Diabetes Testing Supplies - Must Check 
 5. Testing Frequency 
 10. Prescriber Name: JOSHUA DUBOSE 
 NPI: 1700997665 
 PLEASE 
 Address: 804 W MONTGOMERY ST 
 INITIAL AND 
 City: WILLIS 
 State: TX 
 Zip: 77378-8830 
 DATE ALL 
 CHANGES 
 Prescriber Signatures 
 Date: 
 29 Mar 2018 
 (Handwritten Signature and Date Required) 
 Fax Form To: 1 866 855-5888 or mail original form to: Walgreens Medicare Processing, P.O. Box 4000 Danv眉le, IL 61834-4000 
 Questions? Contact the Walgreens Medicare Part B documentation department at: 1-888-281-0590 between the hours of 8:00-4:30 CST 
 Please note that this document does not constitute the patient's Medical record. If this claim is audited by Medicare you could be required 
 to provide additional documentation. 
 C0011041536 
 Name: Jeremy Gomez 
 DOB: 10 Oct 1987 
 Date:
