Physical Therapy Products - Balance Training Equipment

Medical Insurance Verification

Medical Supply Item You Are Looking For

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(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:	*
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 not accept Medicare or Medicaid as your Primary Coverage.
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Worker Compensation:	Yes No * *
Primary Insurance Company 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
Email 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 physical therapy products. We will contact you shortly to arrange shipment of your device, and to discuss the details of your claim.

© Copyright 2008 Orbital Industries Inc.. All Rights Reserved.

continuous passive motion devices, physical therapy products, increase range of motion, increase blood flow, continuous passive motion equipment, rehabilitation devices, recovery of joints