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 FormPatient First NamePatient Last NamePatient Date of BirthPatient Gender- Select -MaleFemaleOthersPatient Phone no.Primary Health Insurance Name:Primary Health Insurance ID:Secondary Health Insurance Name:Secondary Health Insurance ID:Street AddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryUnited States (US)Required Braces Type:Upper BackLower BackLeft ShoulderRight ShoulderLeft HipRight HipLeft AnkleRight AnkleLeft ElbowRight ElbowLeft WristRight WristShoe SizeWaist SizeHeightWeight LBPrimary Care Physician NamePhysician Phone NumberSubmit Your Request
