Call:
209.845.7813
Fax: 213.226.4613
Facility name:
Person Ordering and Title
Address
Your phone number:
Patient
One call does it all!
We handle all paperwork
and billing!
No charges to the Facility
!
What you need in as little
as three days!
We are HIPAA Complaint!
Left
Right
Needed Measurements
Circumference of thigh:
inches
Circumference of calf:
inches
getting the size right
Medicare Part B
(fax face sheet and T.O,)
T.O. sample: PT eval and splinting of the lower extremity or similar wording.
Medicaid (TAR may be required if so expect 4 to 6 week delivery,
fax face sheet
)
HMO Doctor must contact HMO for authorization (
fax approval letter from HMO
)
Responsbile Person &
telephone number
Family $180.00
Facility $180.00
Administrators Name
We will invoice the facility and family
Fax needed
documentation
as indicated..
We will call you to verify receipt...
We cannot process order until we receive
documentation
and
verify status!