TENS Rx - Your Real Time Health Care Solution

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Secure Internet Services

If you are a participating TENS Rx doctor, use this secure online pre-authorization form to check on benefits for your new patients. We will call your office with an update within 24 hours!

Required fields

Doctor Information Doctor's Name Your Medical Sales Consultant’s Name

Patient Information Patient’s Name (as it appears on the insurance card) Date of Next Appointment Time of Next Appointment (only applicable if your Patient's appt is within the next 48 hours) Unit Type Patient's Date of Birth Patient's Social Security # Prescribed Duration Diagnosis Codes

Insurance Information Insurance Company Insurance Company Phone # With this patient's insurance, my office is Policy # (including alpha prefix) Group # Name of Insured

Auto or Worker’s Comp Information Auto or Worker’s Comp Company Auto or Worker's Comp Company Phone # Adjuster's Name Claim Number Date of Accident Attorney's Name

Pre-Authorization Form

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