CPR Medical
 Electrotherapy (T.E.N.S.) Order Sheet
Fields in red are required for completion.

INSURANCE INFORMATION

 

Referring Insurance Company 
 Your Name                                 
   		 email
Insurance Address    

 
Insurance City
 State      
         		  Zip (12345-6789)
Phone (123-456-7890)                                   
                                                		 Fax (123-456-7890)

Complete only if different from above

  
Bill To Insurance Company
 		Adjuster
Bill To Address

  
Bill To City
 State       
         		 Zip (12345-6789)
Phone (123-456-7890)                               
                                   
 		 Fax  (123-456-7890)

CLAIMANT INFORMATION


Claimant Name
  
Claimant Address

  
Claimant City
 State      
         		 Zip (12345-6789)
Home Phone (123-456-7890)            Work Phone (123-456-7890) 
                          
Claim Number                                  Policy Number
           		Social Security # (123-45-6789)
Date of Injury (mm/dd/yyyy)       
                               		   Date Of Birth (mm/dd/yyyy)
 Accident Type
 
Sex                    
      		 Deductible Amount (if applicable)
Employer Name
  
Employer Address

  
Employer City
 State      
         		  Zip (12345-6789)
Employer Phone (123-456-7890)
 
Dr. Name  
Dr. Phone (123-456-7890)                           
                                    		 Dr. Fax (123-456-7890)
Therapist
 Therapist Phone  (123-456-7890)
ICD9 Code
  
ICD9 Description
  
Authorization Number (if needed for billing)

 		  

EQUIPMENT & SHIPPING INFORMATION


 Unit Type
"Economy" Units
TENS
Clinical Devices - TX-3TA
MUSCLE STIMULATOR
Bio Medical - BioStim NMS

"Basic Plus" Value Priced TENS Units
Bio Medical - Systems 2000
Rehabilicare - Maxima

Premium TENS Units

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Rehabilicare - NuWave
Empi - Eclipse Plus
Empi - Dynex V
Danmeter - Elpha II 1000

Microcurrent (MENS) Units
BioMedical - Micro Plus
Specialty Units 
Muscle Stimulators
Rehabilicare - NM III
Rehabilicare - EMS +2
Danmeter - Elpha 2000

Galvanic Stimulators
Rehabilicare - GV II
MEA - Neuro HV
BioMedical - GV350

Galvanic &  Muscle Stimulators
Jace - TriStim

Galvanic &  TENS Stimulators
Rehabilicare - SporTX

Interferential Stimulators
BioMedical - INF Plus
U.S. Therapy Products - HMP 4000
Rehabilicare - IF2
Med Direct - Fast Start IF

Biofeedback (EMG)
Thought Technologies - MyoTrac EMG

 
Other Unit
Please specify brand and model of unit below:

E-Stim Supply Conversion (Claimant only needs supplies for their E-Stim Unit)
Supplies Only

Comments:

Please note, we currently only offer items from our electromedical program on this site.  
Other items from our DME program are available by calling (800) 235-5675.

Special Shipping Instructions
Units will be sent to the patient's address above, unless specified otherwise below.
Ship to Name
  
Ship To Address

  
Ship To City                                                                          State     Zip (12345-6789)
         
All orders are shipped via UPS 3 Day Select, unless otherwise specified below.  
Special Shipping

  
Other Comments:

 

   IMPORTANT !!! - PLEASE E-MAIL OR FAX A PRESCRIPTION WITH THIS ORDER. 
WE CANNOT SEND AN ELECTROMEDICAL DEVICE WITHOUT A PRESCRIPTION.
Fax (724) 337-0556

 

YOU WILL RECEIVE A CONFIRMATION OF THIS ORDER WITHIN ONE BUSINESS DAY, VIA EMAIL.
IF YOU DO NOT RECEIVE THIS CONFIRMATION, PLEASE CALL US AT 1-800-235-5675

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