Express Verification Form
Please provide the necessary details for verification.
SMG MEDIQUIP, LLC
P.O. BOX 736, BETHPAGE, NY 11714
PHONE: 516-586-4934 / FAX: 800-717-2573
Physician Information
Physician Name
*
Physician Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date
*
-
Month
-
Day
Year
Date
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Insurance Company
*
Insurance Type
*
MajorMed
Workers’ Comp
No-Fault/Auto
Insurance Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance ID / Claim #
*
Date of Injury/Accident (if applicable)
-
Month
-
Day
Year
Date
Equipment Requested
*
Tens
Lumbar Brace (LSO)
Lumbar Traction Unit
Thoracic Brace (TLSO)
Postural Brace (TLSO)
Knee Brace
Cervical Traction Unit
Other
For Workers’ Comp, indicate Employer if known
Patient Information 2
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Insurance Company
Insurance Type
MajorMed
Workers’ Comp
No-Fault/Auto
Insurance Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance ID / Claim #
Date of Injury/Accident (if applicable)
-
Month
-
Day
Year
Date
Equipment Requested
Tens
Lumbar Brace (LSO)
Lumbar Traction Unit
Thoracic Brace (TLSO)
Postural Brace (TLSO)
Knee Brace
Cervical Traction Unit
For Workers’ Comp, indicate Employer if known
Patient Information 3
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Insurance Company
Insurance Type
MajorMed
Workers’ Comp
No-Fault/Auto
Insurance Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance ID / Claim #
Date of Injury/Accident (if applicable)
-
Month
-
Day
Year
Date
Equipment Requested
Tens
Lumbar Brace (LSO)
Lumbar Traction Unit
Thoracic Brace (TLSO)
Postural Brace (TLSO)
Knee Brace
Cervical Traction Unit
For Workers’ Comp, indicate Employer if known
Submit
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