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  • 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.

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  • Secondary Insurance

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  • 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:

    1. Patient Order Form (this form)
    2. Physician's Written Order (completed by the prescriber)
    3. If using insurance, 5-10 pgs of chart notes relevant to this diagnosis and order
    4. If using insurance, a copy of the front and back of insurance cards to be billed
  • 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.

     

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