I would like to verify my insurance to see if I qualify for Durable Medical Supply (DME) coverage

Please provide us with your doctors information and your insurance information. We will contact you with coverage information.

* HMO, Medicare and Medicaid Not Accepted *

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Patient - Full Name *

Date of Birth *

Address *

City *

Zip / Post Code *

Phone Number *

Email *

Insurance Company *

Name of Subscriber *

Subscriber ID *

Group Number *

Insurance Phone Number *

Doctors Name *

Doctors Phone Number *

Doctors Fax

DME Products You Are Inquiring About

• TENS Unit
• Lumbar Support
• Cervical Traction
• Replacement Electrodes
• Conductive Garment
• Knee Brace
• Carpal Tunnel Brace
• Elbow Brace

Comments

*