Referring a patient to Liberty® is easy, for both you and your patient.
Simply download the form below and have the patient fill it out and submit it.
New Patient Form
Patient Information Form (PIF) – An efficient way of referring patients for any prescribing facility, this form will allow the office and patient to submit a prescribed testing regimen, document patient demographics, submit order information, and satisfy insurance-mandated paperwork requirements all in one form.
Patient Referral Form
Patient Referral Form (PRF) – A streamlined method of referral, this form makes it easy for any non-prescribing facility that wants their patients to benefit from Liberty’s services. Your patient will thank you once they start enjoying the many advantages of being a Liberty Customer.
Resources for your Patients
- Free delivery of supplies
- Quality products from top brands
- 90-day no-risk guarantee*
- Reorder reminders
- Easy-to-navigate website that includes:
-- Access to CDEs
-- Insulin Pump Center of Excellence
-- Latest information on meters
-- Liberty Healthy Living™ Program