Insurance Verification Form

If you have been injured on the job, or if you have an injury that requires a pain management product, then we have a program for you. In most cases, insurance companies will pay 80%-100% of costs of a TENS Unit, Back Brace, Knee Brace, and any additional supplies needed. Please complete the insurance verification form, link to form has been provided, and 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  Back Brace  Knee Brace  Others   
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 Healiohealth 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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