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Request for Medicare and Insurance Covered Back Support

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* Required information.

ABOUT YOU

First, we need a little information about you.  Please type your name exactly as it appears on your insurance card.  We NEVER share your contact information with anyone not related to this transaction--we value your privacy as much as you do!

Your Name: * Please type your name exactly as it appears on your insurance card.
Street Address: * Please provide your street address, including any suite or apartment numbers
City, State ZIP: *
Waist Size (inches): * Please enter your waist size, in inches.  This helps us assure a great fit!
Birth Date: * Please enter your date of birth.  We are required by insurers to ask for this to help validate your request.
Phone Number: * Please provide the best telephone number for us to use to contact you if we have questions in the fulfillment of your product request.
eMail Address: *

YOUR PHYSICIAN

We will contact your physician on your behalf to verify the product you are requesting is appropriate for you.

Doctor's Name: * Please provide the name of your physician so that we can contact him or her to request a prescription for your product request.
Doctor's Phone #: * Please provide the phone number for your doctor's office so we may contact him or her as needed to help us fulfill your request.

PRIMARY INSURANCE

Please provide your primary insurance details.  If you would prefer not to provide this information via this web form, simply select your primary insurance type, the leave this section blank and we will call you to request the information.

Insurance Type: *
Insurance Company: Please enter the name of your private insurance company, if not Medicare or Medicaid
Member# or ID#: Please enter your insurance ID number or Medicare number.
Group #: Please enter your insurance group number.
Phone Number: Please provide your insurance company's phone number (from your card)

SECONDARY INSURANCE (if any)

If you have secondary or supplemental insurance, please provide the details here--otherwise you can leave this section blank.

Insurance Type:
Insurance Company:
Member# or ID#:
Group #:
Phone Number:

PATIENT PERMISSION: 

I authorize CarePoint Medical to contact me, my doctor, as well as Medicare, Medicare supplement, Medicaid or other insurance(s) for release of medical and other information in order to obtain products requested.  By typing my name in the following field, I am providing my electronic signature to authorize CarePoint Medical to submit a claim on my behalf and that assignment of Medicare, Medicare supplement, Medicaid or other other insurance benefits for items obtained from CarePoint Medical be paid directly to CarePoint Medical.

Electronic Signature (Type Your Name): * By typing your name in this box, you are electronically signing the above agreement, submitting this form, and you are certifying that you are the person named at the top of this form.
Electronic Signature Date: * Please confirm the date on which you are electronically signing this form.

Other Products That May Benefit You

I am willing to allow CarePoint Medical to call me regarding future medical products and services that may be of benefit to me:
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