Medicare/Insurance Form

Use this form to check for medicare/insurance coverage.

This form is required if you are going to purchase any of our products at prescription pricing.

General Information

All fields in this section are required!

First name:*
Last name:*
Email:*
Street Address:*
City:*
State:*
Zip Code:*
Phone #:*
Birth Date:*
Sex:*
Male Female

Medicare/Insurance Information

Insurance ID#:

Secondary Insurance

Secondary Ins. Policy #:
Group ID#:
Address:
City:
State:
Zip Code:
Telephone:

Physician

Primary Care Physician:
Telephone:
Fax:
Address:
City:
State:
Zip Code:

Signature and Disclaimer

*My initials or printed name entered below legally represent my signature signifying that all information I have entered above is mine and that I have been given the opportunity to read and do approve of the three forms directly below.

Hipaa Privacy Notice
Medicare Supplier Standards
AssignmentNotice

E-Signature:*

Code Below:*

Security Image


Explore Here!

SOMAerectStf™ SOMAerectStf™
Encore Deluxe System Encore Deluxe System
Vitality Vitality
Eros Eros

© 2012 VEDSystems.com. In partnership with Pro Comfort Medical.

Home | Contact | Blog | Sitemap | Bookmark | Return Policy | Utah Web Design

You should assume that the owner of this website is an affiliate for providers of goods and services mentioned on this website. The owner may be compensated when you purchase after clicking on a link.