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Ultra Motion CPM
Legs Rock 'n Roll
Dual Orbital Workout
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Medical Insurance Verification
Medical Supply Item You Are Looking For
(details please view below links)
 UltraMotion CPM 
 Legs Rock N Roll CAM 

Will you be using the unit? Yes  No
Patient Name:
Home Phone:
Email:
Employer:
Is your insurance through your employer? Yes  No
Work Phone:
Extension:
Date of Birth:
Soc. Sec # of Patient:
Address:
City:
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Physician Name:
Phone:
Address:
City:
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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 not accept Medicare or Medicaid as your Primary Coverage.
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:
Note:


Assignment of Insurance Benefits

I hereby Authorize payment of medical benefits to Orbitalindustries.com, Orbital Enterprises 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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Please note we need a prescription to submit an insurance claim. If you already have a prescription, please fax or mail this to us as soon as possible. If you do not have a prescription, please print our online prescription form, have your physician sign it, then fax or mail this form to:

www.orbitalindustries.com
6850 Cochran Road
Solon, Ohio 44139
E-mail Sales@orbitalindustries.com
FAX: (440) 349 5102, or CALL (440) 349 5912


Thank you for choosing www.orbitalindustries.com for your medical supply needs. We promise excellent customer service and superior products. We will contact you shortly to arrange shipment of your device, and to discuss the details of your claim.


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