Nebulizador PARI Copa Formulario de Pedido

PARI Nebulizer Cup Order Form

Your Information
Patient First Name*
Patient Last Name*
Parent / Guardian First Name
Parent / Guardian Last Name
Street Address*
Apt./Unit
City*
State*
ZIP Code*
Email*
Phone*
Physician's Practice or Clinic Name*
Prescribing Physician Name*
Clinic Phone Number*
Physician Fax Number
Insurance Information
Insurance Type*
Member ID (Letters & Numbers)*
Insurance Phone Number*
Please Read and Sign
- I understand that Neb Doctors of Maryland, LLC or its assignee (“Provider”) is independently owned and operated and is not in any way associated with a hospital, medical practice or any other clinic.
- I certify that the information provided by me and applying for payment under title XVIII (Medicare) of the Social Security Act of any other insurance benefits is true and correct.
- I understand that if my insurance coverage is denied, I am responsible to pay Provider the usual and customary amount/ price for this equipment.
- I authorize release of all medical records needed in relation to the above referenced equipment.
- I request that a payment be made to Provider by my insurance company, Medicaid, Medicare or government benefits.
Please check box to agree:*
- I certify that I have read the terms and conditions of this agreement, any attachments and agree to its content.

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