Compression Patient Information
A member of the compression department will reach out within 72 business hours (M-F) AFTER the completion of this form to set up an appointment for a compression fitting. If you have any questions please call us at 804-288-8361 ext 134.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address ( Must be in the state of Virginia)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter valid phone number
Email
example@example.com
Please Select Primary Insurance
Please Select
Anthem
Medicare- Lymphedema patients ONLY
*Of note: Medicare will cover compression 80% only for Lymphedema patients and chart notes are required from physician
Please list insurance ID (Include the first three letters) and group number. We are only able to accept Anthem Insurance at this time.
ID Number
Group Number
Please upload a copy of the front and back of your Anthem insurance card. You must have a script in order to use your insurance.
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Please select the style of compression needed.
Calf High
Knee High
Pantyhose
Thigh with waist
Maternity
Armsleeve
Glove
Gauntlet
Compreflex
Please select the compression strength needed.
15-20
18-25
20-30
30-40
40-50
50-60
Would you like your compression to be open or closed toe?
Open Toe
Closed Toe
Do you have a prescription for the item(s) selected above?
Yes
No
Please list your doctor's name.
First Name
Last Name
Please list your doctor's phone number.
Please enter a valid phone number.
Please list the diagnosis code or reason listed on the prescription of why this is being prescribed.
ICD-10 Code ex R60.0 (edema)
Please upload a copy of your prescription.
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