authorization form for the fisher wallace...

AUTHORIZATION FORM FOR THE FISHER WALLACE STIMULATOR The authorization can be written out on a regular prescription pad. If not in the form of a prescription, the following authorization form is to be filled out by a licensed healthcare practitioner and faxed to (800) 657 - 7362 or emailed to [email protected]. Patients may then purchase the device through our website - www.FisherWallace.com Questions? Call us at (800) 692 – 4380 Date: ___/____/____ I am authorizing the use of The Fisher Wallace Stimulator for _____________________, PATIENT’S NAME for the treatment of ____________________________________. Device Procedure Code: E0720 Diagnosis Code(s): ______________________ PRACTITIONER’S SIGNATURE PRACTITIONER’S INFORMATION Practitioner’s Name: Practitioner’s Address: City: State: Zip code: Phone Number: State License Number: PATIENT INFORMATION Patient Name: Patient’s Address: City: State: Zip code: Phone Number: ______________________________

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AUTHORIZATION FORM FOR THE FISHER WALLACE STIMULATOR

The authorization can be written out on a regular prescription pad. If not in the form of a prescription, the following authorization form is to be filled out by a licensed healthcare practitioner and faxed to (800) 657 - 7362 or emailed to [email protected]. Patients may then purchase the device through our website - www.FisherWallace.com Questions? Call us at (800) 692 – 4380

Date: ___/____/____ I am authorizing the use of The Fisher Wallace Stimulator for _____________________,

PATIENT’S NAME for the treatment of ____________________________________. Device Procedure Code: E0720 Diagnosis Code(s): ______________________

PRACTITIONER’S SIGNATURE

PRACTITIONER’S INFORMATION Practitioner’s Name: Practitioner’s Address:

City: State: Zip code:

Phone Number:

State License Number:

PATIENT INFORMATION Patient Name: Patient’s Address:

City: State: Zip code:

Phone Number:

______________________________

Page 2: AUTHORIZATION FORM FOR THE FISHER WALLACE STIMULATORfitandsuperhealthy.com/Research_Articles/FW/written... · · 2013-12-18AUTHORIZATION FORM FOR THE FISHER WALLACE STIMULATOR The

INSURANCE COVERAGE NOTES

(this page does NOT need to be sent over with the authorization)

• Insurance companies reimburse for the device more readily when it’s prescribed for any kind of pain (general pain, chronic pain or any other kind of skeletal or muscular pain). When prescribed for depression, anxiety and/or insomnia, the reimbursement rate may decrease significantly.

• Fisher Wallace Laboratories does not process reimbursement paperwork on behalf of its customers, but will assist customers during the process, as needed. We are out of network for all insurance companies.

• The customer needs to call their insurance company, provide them with the device reimbursement code (procedure HSPCS code) and the diagnosis code, which should be supplied by the healthcare professional and present on the written authorization. The insurance company then typically sends a DME (Durable Medical Equipment) claim form which needs to be filled out with all the above-mentioned information and attached to the proof of payment and written authorization. When you purchase one of our devices, you will receive an automatic email receipt that includes our Federal Tax ID#, out NPI# and the reimbursement code for our device.

• Please review the insurance page on our website available under the menu option Customer Service or by typing in the following link into your address bar: http://www.fisherwallace.com/insurance-payment-and-reimbursement