Interferential Therapy Electrotherapy Device

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In most cases, insurance companies will pay 80%-100% of costs for a TENS or EMS unit and/or monthly electrodes and supplies. Please complete the insurance verification form below, all information is sent via secure server. We will verify your insurance coverage and contact you within seven business days regarding your approval.

I would like coverage for:

TENS Unit EMS Unit IF 4000 Microcurrent Galvanic Stimulator Diabetic Shoes

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:

SOC.SEC#: OF PATIENT:

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 or 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 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.

info@paintechnology
888-267-5422