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Home > Braces Patient Registration Form

Braces Patient Registration Form

Patients with health insurance coverage can apply for DME Supplies such as Braces. To request Braces supplies, please provide the following information:

Patient Information:

Step 1

Primary & Secondary health insurance details

Step 2

Primary care physician name & contact information

Step 3

We will contact the patient's primary care physician to obtain the necessary prescription and chart notes.

Step 4

We will submit the required documentation to the patient's primary health insurance provider.

Step 5

We will obtain pre-authorization for the DME Supplies.

Step 6

We will ship the approved DME Supplies directly to the patient's address.

Patients can follow up on the status of their order by calling (321) 616-7867.

Braces Patient Registration Form

Doctor Office Details

Please update doctor office information. 

Please make sure you have provided valid chart notes and prescription. Any kind of editing on chart notes and prescription is strictly prohibited.

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