Insurance


In order to submit your custom facemask for billing to your primary insurance, we will need you to fill out the appropriate form from the selection below and return them to us with a copy of your drivers license and insurance card. Our billing department will be happy to pre-authorize all insurance claims to determine if your personal insurance has orthotics coverage (what your facemask will be considered) and Michigan Hand and Sports Rehab Centers participation with your insurance carrier. All claims not covered by insurance will be billed directly to the patient. Please feel free to contact us or our billing department at (586) 573-8890.

Blue Cross Blue Shield Forms

Acknowledge Good Faith
Assignments of Benefits
Splint Orthotic Agreement
Coordination of Benefits Information
Preamble

Medicare Forms

Acknowledge Good Faith
Assignments of Benefits
DME Patient Form
Medicare Questionaire
Preamble
Durable Medical Equipment Benefits

Private Insurance Forms

Acknowledge Good Faith
Assignments of Benefits
DME Patient Form
Medicare Questionaire
Durable Medical Equipment Benefits
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