Health Coverage Verification Request Form

Patient Information.

Your health insurance may provide coverage for some select products. Please complete this form, and we will do the work for you!

Customers may initiate communications with resources using e-mail. If this situation occurs, can assume (unless the customer has explicitly stated otherwise) that e-mail communications are acceptable to the individual. By contacting you are acknowledging the possible risks of using unencrypted e-mail, or understand the concerns about potential liability.