Prescription Form-- Letter of Medical Necessity 866-633-6261

Physician notes, previous treatments 866-633-6262 fax

Patient Name: Kimberly Schreiber Patient Date of Birth

Patient Address Patient Phone

(Auto or W/C) Claim #

(Auto or W/C) Date of Accident

Insurance Co. Insurance ID # Group #

Patient Data & Lien

Insurance Phone Insured's Name

Patient Agreement

hereinafter referred to as *The Company, will be the supplier. I understand that this
equipment is to be used for my diagnosed condition and is issued under a doctor’s prescription. I absolve The Company
of responsibility as a result of any accident or injury caused directly or indirectly while using the equipment. I authorize
The Company to provide supplies as needed. I authorize the release of medical records to The Company in order to
determine benefits and to assist in correspondence with any third parties regarding collections of benefits on my behalf. I
authorize payment of medical benefits directly to The Company. A copy of this authorization is as valid as the original. I
understand that The Company is HIPAA compliant and will protect my privacy with regard to my medical and personal
information. I acknowledge receipt of “Notice of Privacy Practices and CMS Medicare DMEPOS SUPPLIER
STANDARDS”. By my signature below, I am acknowledging receipt of this equipment.

Patient Signature Date Serial #

Equipment Prescribed :
( ) TENS / EMS unit Purchase ( ) E0855 Cervical Traction Device
( ) Supplies for TENS/EMS ( ) Water Circul. heat/cold pump w/pad
X L0631 Lumbar Brace ( ) Pad for water circulation heat unit
Physician Notes / Previous Treatments / Letter of Medical Necessity

( ) Other ( ) Conductive Brace / Wrap / Garment

Lumbar Knee Ankle
Recommended Usage:

Period : Area to be treated

ICD ( Codes Applicable) Prognosis Excellent Good Fair Guarded

Area to be treated

Previous Treatments

Pain Severity Chronic Severe Intractable

Mild Moderate Date First Diagnosed

Symptoms: Date Last Seen

I certify that the above prescribed equipment, as provided by The Company is both reasonable and
medically necessary as part of my treatment plan for this patient's condition as stated herein. This
prescription is valid for one year from the date indicated unless otherwise noted. I authorize no substitute for
the equipment prescribed.

PO Box 550747
Physician's Signature Date Address
Atlanta GA 30355
Dr. Alesia Reynolds City State Zip Code
Printed Name 404-477-1797 404-477-1897
NPI Phone Fax

1 Patient Data / Script

Prescription Form-- Letter of Medical Necessity 866-633-6261
Physician notes, previous treatments 866-633-6262 fax

1 Patient Data / Script