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: Please Select One.. Dee Berrios Erin Houlihan Karah Waldo Kelly Macdonald Lori Tucker Melissa Harmon Paula Genser Tracie Harrell

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: Please Select One.. Body Select and supplies Dual Combo and supplies Complete 4-in-1 and supplies DDS Double DDS 500 Cervitrac Kneetrac Patient's Date of Birth: Patient's Social Security #: Prescribed Duration: 9 months 1 year Diagnosis Codes:

Insurance Information

Insurance Company: (*) Insurance Company Phone #: With this patient's insurance, my office is: In Network Out of Network 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: