Forms and insurance information

Atos Medical Inc. will file claims for durable medical equipment (DME) orders.  For an insurance claim to be filed, the following needs to be completed and returned to our office:

  • Front and back copies of all insurance cards
  • Prescription/Diagnosis Form (including frequency of replacement)
  • Patient Insurance Information (PIIF) Form
  • Patient Service Agreement (PSA) Form

The type of DME equipment ordered, laryngectomy supplies or jaw motion rehabilitation supplies, will determine which forms are to be completed.

Insurance Information Packet

Complete with:
Important Insurance Filing Notice
Patient Insurance Information Form
Patient Service Agreement
Prescription/Diagnosis Form
Ordering Supplies Information
Primary Product Listing
Patients Bill of Rights and Responsibilities
Medicare and Private Insurance Q&A
CMS DMEPOS Supplier Standards

Insurance Information Packet

Laryngectomy Insurance Information Packet 
Jaw Motion Rehabilitation Insurance Information Packet

Prescription/Diagnosis Forms

Must be completed by treating physician.

Prescription Diagnosis Form Laryngectomy

Prescription Diagnosis TheraBite


Laryngectomy Prescription/Diagnosis Form 
Jaw Motion Rehabilitation Prescription/Diagnosis Form 

Health Insurance Portability and Accountability (HIPAA) Information

This notice describes how medical/health information  may be used/disclosed and how it can be accessed.

HIPAA Packet


HIPAA Information Packet

Medicare Compliance Letter

An affirmative statement by the Medicare beneficiary instructing Atos Medical not to file a claim to Medicare on the beneficiary's behalf when purchasing durable medical equipment, L8509, indwelling voice prosthesis.  The beneficiary does not desire a Medicare claim to be filed and therefore understands there is no further appeal for payment.