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.

 

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