Covered by Insurance

On line insurance form to verify coverage for Infrex, Tens and other medical equipment

Details: Category: Covered by Insurance; Hits: 12220

I would like coverage for:

TENS Unit Muscle Stim Unit Infrex Plus Microcurrent

Would you like monthly supplies? Yes No

Will you be using unit for pain? Yes No

PATIENT NAME:

HOME PHONE: - (Area Code plus the Phone Number)

EMAIL:

EMPLOYER:

Is your insurance through your employer? Yes No

WORK PHONE: - Extension:
(Area Code plus the Phone Number)

DATE OF BIRTH:

ADDRESS:

CITY:

STATE:

ZIP CODE:

PHYSICIAN NAME:

PHONE: -

ADDRESS:

CITY:

STATE:

ZIP CODE:

Do you have a prescription: Yes No

(If NO, one needs to be obtained) can you obtain one:
Yes No

What kind of coverage plan do you have?

We do accept Medicare and in some states Medicaid.

Worker Compensation : Yes No

PRIMARY INSURANCE CO. OR MCO NAME:

PHONE: - (Area Code plus the Phone Number)

POLICY/GROUP OR CLAIM #:

SOC.SEC#: OF INSURED:

PATIENT:

NAME OF INSURED:

D.O.B. OF INSURED:

EMPLOYER OF INSURED:

RELATIONSHIP TO PATIENT:

Assignment of Insurance Benefits

I hereby Authorize payment of medical benefits to Medfaxx for services furnished. I further authorize the release of any medical information required to process an insurance claim on my behalf. I permit a copy of this authorization to be as valid as the original.