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

Patient Name

Date of Birth

Select an Address

If patient is currently under a surgical global period, please indicate date and procedure completed

Date of procedure

PHYSICIAN AND FACILITY INFORMATION

Treating facility place of service (POS)

Hospital-based outpatient wound department (HOPD - POS 22)

Physician office (POS 11)

Ambulatory surgery center (ASC - POS 24)

Other (please specify, e.g. critical access hospital or POS 19 off-campus)

Select an Address

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

Anticipated treatment start date

Diabetic foot ulcer

Venus leg ulcer

Pressure ulcer or chronic wound

Other

I certify that I have obtained a valid authorization under applicable law from the patient listed on this form (a) permitting me to release the patient's protected health information to Legacy Medical and its contractors (Best Lab Tests) to research insurance coverage regarding Legacy Medical products, and to provide me with reimbursement assitance services regarding such products; and (b) authorizing the payer to disclose PHI to Legacy Medical and its contractors for the purposes of determining benefit coverage.

Provider Signature

Date signed

Please upload the front and back of patient's insurance card

Upload File

Thanks for submitting!

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.

Customer Service 323-985-TEST (8378) SUPPORT@BESTLABTESTS.COM

Locations
Testing In All 50 States
Home Office
6801 Lake Plaza Dr.
Indianapolis, IN 46220

Links
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CONTACT INFO
323-985-TEST (8378)
support@bestlabtests.com
BUSINESS HOURS
Monday - Friday 9am - 5pm EST
Sundays & Holidays closed