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BEGIN ORDER

Step 1 - Begin patient insurance verification below and receive a benefits report within 24-48 hours.
Step 2 - Order the proper size patch from your rep for $0 upfront with free overnight shipping.
Step 3 - Pay your invoice within 30 days of ordering minus your 40% rebate.

Patient Insurance Verification and Prior Authorization Request Form

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Treating facility place of service (POS)

Product and Treatment Information

Product: Q4253 Zenith Membrane

Application Codes: 15271 -- 15274 for wounds on the trunks, arms, and/or legs

                            15275 -- 15278 for wounds on the face, scalp, eyelids, mouth, neck ears, orbits, genitalia, hands, feet, and/or multiple digits

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Disclaimer: Legacy Medical offers insurance verification as an information service only. Information gathered during the requested research will be provided by the insurer or third-party payer. Results of this research are not a guarantee of coverage or reimbursement in the future. Legacy Medical and Best Lab Tests disclaim liability for payment of any claims, benefits, or costs.

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