I WOULD LIKE COVERAGE FOR: TENS Unit EMS Unit IF 4000 Microcurrent Galvanic Stimulator Diabetic Shoes PATIENT NAME EMAIL HOME PHONE EMPLOYER IS YOUR INSURANCE THROUGH YOUR EMPLOYER? Yes No WORK PHONE DATE OF BIRTH SOC.SEC#: OF PATIENT: ADDRESS CITY STATE ZIP PHYSICIAN NAME PHYSICIAN PHONE ADDRESS CITY STATE ZIP What kind of coverage plan do you have? Indemnity - 80/20 Indemnity - 70/30 Indemnity - 60/40 Preferred Provider POS W.C. Medicare Medicaid Other Worker Compensation Yes No PRIMARY INSURANCE CO OR MCO NAME PHONE 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 Microcurrent Shoes for services furnished. I further authorize the release of any medical information required to process an insurance clain on my behalf. I permit a copy of this authorization to be as valid as the original. Security code:   * Do not enter anything in this field:

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