I would like coverage for:
Would you like monthly supplies? Yes No
Will you be using unit for pain? Yes No
PATIENT NAME:
HOME PHONE:
EMAIL:
EMPLOYER:
Is your insurance through your employer? Yes No
WORK PHONE:
Extension:
DATE OF BIRTH:
SSN OF PATIENT:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHYSICIAN NAME:
PHONE:
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 or Medicaid. Indemnity - 80/20 Indemnity 70/30 Indemnity - 60/40 Preferred Provider P.O.S. W.C. Medicare Medicaid Other
Worker Compensation: Yes No
PRIMARY INSURANCE CO. OR MCO NAME:
PHONE: - (Area Code plus the Phone Number)
POLICY/GROUP OR CLAIM #:
SSN 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 Pain Management Technologies 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.
