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INSURANCE APPLICATION
In most cases, insurance companies will pay 80%-100% of costs for a TENS or EMS unit and/or monthly electrodes and supplies. Please complete the insurance verification form below, all information is sent via secure server. We will verify your insurance coverage and contact you within seven business days regarding your approval.

I would like coverage for:
TNS Unit EMS Unit IF 4000 Microcurrent

Would you like monthly supplies?
Yes No

Will you be using the unit for pain?
Yes No

PATIENT INFORMATION

PATIENT NAME:
HOME PHONE NUMBER:	- - (xxx-xxx-xxxx)
EMAIL ADDRESS:	(use full Internet address)
EMPLOYER:
SS#:	- - (xxx-xx-xxxx)
Is your insurance through your employer? Yes No
WORK PHONE:	- - EXT.
DATE OF BIRTH:	/ / (month-day-year)
HOME ADDRESS:
CITY:
	STATE: ZIP:

PHYSICIAN INFORMATION

PHYSICIAN NAME:
PHONE NUMBER:	- - (xxx-xxx-xxxx)
ADDRESS:
CITY:
	STATE: ZIP:
Do you have a prescription? Yes No
IF YOU DO NOT have a prescription you will need to obtain one. Can you? Yes No

COVERAGE INFORMATION

What kind of coverage do you have? We do not accept Medicare or Medicaid.	Indemnity - 80/20 Indemnity - 70/30 Indemnity - 60/40 Preferred Provider P.O.S. W.C. Other
Worker Compensation? Yes No
PRIMARY INSURANCE CO. OR MCO NAME:
PHONE NUMBER:	- - (xxx-xxx-xxxx)
POLICY/GROUP OR CLAIM #:
SS# OF INSURED:	- - (xxx-xx-xxxx)
PATIENT:
NAME OF INSURED:
DATE OF BIRTH OF INSURED:	/ / (month-day-year)
EMPLOYER OF INSURED:
RELATIONSHIP TO PATIENT:

Assignment of Insurance Benefits
I hereby Authorize payment of medical benefits to TENS UNITS 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.

Email Questions
info@ tensunits.com