Primary Insurance
By completing this section, I authorize Daavlin or its billing agents to verify my insurance benefits for DME. I authorize direct billing to my insurance, assignment of benefits to Daavlin or its billing agents and release of medical records necessary to process my insurance claim. I understand there is no obligation to purchase to receive free verification of my insurance benefits, but once I instruct Daavlin or its billing agent to ship my order, payment in full is my responsibility.
Secondary Insurance
Terms & Conditions
By checking the following boxes, you confirm your understanding of and agreement to these Terms and Conditions.
Important! Here are the 4 items Daavlin needs to begin processing your order:
Order Confirmation
By entering my name I hereby confirm that the above information is accurate and complete to the best of my knowledge. I understand that a Physician's Written Order Form, chart notes, and insurance cards (if using insurance) must accompany my order. I have read, understand and agree to Daavlin's Terms and Conditions of Sale Agreement and I understand that all sales of medical equipment are final. I agree to follow my prescriber's instructions for proper use of this medical device.