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PATIENT REORDER FORM












PRIMARY INSURANCE INFORMATION
By checking "Yes", you are aware that money may be deducted from that account and paid directly to insurance billing company.

Yes
No






WOMEN'S COMPRESSION - TOTAL NUMBER OF PAIRS - 8
 

 

 


 



 

MEN'S COMPRESSION - TOTAL NUMBER OF PAIRS - 8


 


AUTHORIZATION TO PAY BENEFIT TO PROVIDER

PRIOR ARRANGEMENTS

HIPPA POLICY AND CONSENT

AUTOMATIC RENEWAL OPTION
we will file a claim for the stockings with your insurance company on file. Your insurance company will pay us directly for the garments. The automatic renewal applies to one calendar year, after which you will need to complete the reorder form again.