PeteHealth Physical Therapy | Braces provided by PeteDME, personalized for you

Verification of Benefits

Confirm with the patient that they carry Medicare + Secondary (generally private insurance). After you fill out this referral, we will contact you to go over details and provide you with patient benefits information. If you have any questions or would like faster service,
please contact us at (888) 859-0029 or dme@petehealth.com

Therapist info

Patient info

Therapist information

Steps 1/2

Therapist first name*

Therapist last name*

Therapist phone number*

Therapist email*

Preferred contact method*

Text

Phone

Therapist info

Patient info

Patient information

Steps 2/2

Is the patient Ambulatory?*
If the patient is not ambulatory, do not proceed

Yes

Do you understand that the brace must be fitted in the patient's home?*
If the patient is currently in the facility you can proceed with the intake process, but the delivery and fitting must take place in the home after discharge.

Yes

Where is your patient experiencing symptoms?*

Back

Knee

Patient first name*

Patient last name*

Patient phone number*

Patient email*

Patient date of birth*

Medicare number* (11 digits)

Medicare insurance card front* (example)

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Max file size 10MB.

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Secondary insurance card front (example)

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Max file size 10MB.

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Secondary insurance card back (example)

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Max file size 10MB.

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Back

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Verification of Benefits

Medical Insurance Examples

Medicare Insurance Card Front

Secondary Insurance Card Front

Secondary Insurance Card Back

Pre-visit inquiries

Patient billing