UPDATED MILLENIUM CLAIM INFORMATION FORM

For patients who are web-users, please print this form, complete, sign, and send to us.

Thank you for your order with COMMUNICATIVE MEDICAL, referred to as CM. Please complete this updated form. We strive to provide quality products and services to our laryngectomee and voice patients. It is very important that you complete this form EXACTLY as directed so we have all the necessary information. Incorrect or incomplete information will greatly hinder services or Medicare reimbursement to you. Please print or type all information requested. For some questions on this form, (i.e., Doctor’s U.P.I.N. number, diagnosis, physician’s address, phone number and prescription) you will need to contact your physician’s office. Do not guess any information. For you and your doctor’s convenience, a preprinted prescription form is on the back of this sheet.

INFORMATION ABOUT YOU

Your Medicare Number: _ _ _ - _ _ - _ _ _ _ (___) Letter Date of Birth:_____-______-______
Last Name:__________________________ First:_____________________________MI:_________
Address:_________________________________________________________________________
City:____________________________State:_________________________Zip_________________
Telephone:(_____)_____________________________ Martial Status:__________________________
Social Security Number: __ __ __ - __ __ - __ __ __ __

YOUR DIAGNOSIS AND YOUR DOCTOR

Your Diagnosis:______________________________________________________________
Physician’s U.P.I.N. Number: __ __ __ __ __ __ Physician's N.P.I. #____________________________
Physician’s Name: Last_______________________First________________________ M__________
Physician’sAddress: _________________________________________________________________
___________________________________________________________________________________
Physician’s Phone Number: (_____)____________________________

INSURANCE AND FINANCIAL INFORMATION

Do you have other health insurance? If yes, provide name, address, and Identification Number.
Company Name:____________________________________________________________________
Is this company your PRIMARY insurer? Yes No Is it a supplement to Medicare? Yes No
Insurance Address:______________________________City_________________ST____ZIP________
Identification Number:________________________Group#______________InsurancePhone#________

PLEASE PROVIDE US WITH...
1. This form with ALL SPACES FILLED IN.
2. A PRESCRIPTION from your doctor. (See reverse or attach existing prescription)
3. A check or money order payable to CM for what you are ordering. You may also use your credit card.
4. A copy of your MEDICARE CARD and/or a copy of your other Medical Insurance I.D. card(s)

6. Acknowledge FINANCIAL RESPONSIBILITY/LIFETIME AUTHORIZATION by signing below.

I request that payment of authorized Medicare/Insurance benefits be made either to me or on my behalf to Communicative Medical. I authorize the release of any medical information to complete this claim. In the event that payment is due, I understand that I am legally responsible for any and all payments with CM, not limited to copayment/deductibles, and I promise to pay CM immediately upon request. All information on this form is true and accurate.

Signature___________________________________________Date___________________________