Tender Tresses Medical Solutions/972-505-5528

I, the undersigned, authorize Tender Tresses Medical Solutions to file a claim with my insurance provider on my behalf for the purpose of reimbursement for a cranial prosthesis (medical wig). I understand that: • A cranial prosthesis may be covered by insurance if medically necessary and prescribed by a licensed physician. • Submitting a claim does not guarantee reimbursement. • I am responsible for any portion of the cost not covered by insurance. • This authorization allows Tender Tresses Medical Solutions to release any necessary information to my insurance company, including medical records, diagnosis codes, and prescription documentation, to process this claim. I further authorize payment of medical benefits directly to Tender Tresses Medical Solutions. This authorization shall remain in effect until revoked in writing by me.