If you have an issue to report to Discount Diabetic please complete the Incident Report below:

* Please fill in required fields.
* First Name:
* Last Name:
Address:
City:
State:	Select a state Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Puerto Rico Guam Virgin Islands America Somosa
* Phone Number:	(e.g. ###-###-####)
* Email Address:
I am:	-- Accredited Organization – Administration Advocacy Agency Anonymous Attorney CAP CMS Employee (current) Employee (former) Family/Significant other of patient Federal Agency Insurance Company JCAHO Employee Managed Care Management Media Other/Not Stated Patient Performance Measurement Data – ORYX Physician Professional – RN, RPH, PT, OT, etc. Public/General State Licensing Agency Technician
* Incident Date:	(e.g. MM/DD/YYYY)
Questions or Comments:

Disclaimer

When submitting a complaint to Discount Diabetic, you may either provide your name and contact information or submit your complaint anonymously. Providing your name and contact information enables Discount Diabetic to inform you about the action taken in response to your complaint, and also to contact you should additional information be needed.

It is our policy to treat your name as confidential information and not to disclose it to any other party. However, it may be necessary to share the complaint in the course of a complaint investigation.

Discount Diabetic encourages the input of concerns and complaints about the safety and quality of care. Discount Diabetic does not take retaliatory actions against patients for having reported quality care concerns. All remarks are looked upon constructively and will not interfere with the service that is provided.

For further questions, please contact us toll free at: 1-800-714-0490