Appointment RequestPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastMailing AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *I prefera phone calltext messagee-mailDate of Birth *Requesting Service *V2624 - Cleaning/Polish ($265 with insurance, 55% discount ($120) for self-pay)V2623 - New Eye Prosthesis ($3,255 with insurance, 35% discount ($2,115) for self-pay)V2627 - New Scleral Shell Prosthesis - a very thin prosthesis to fit over your existing eye ($5,738 with insurance, 35% discount ($3,730) for self-pay)Other...Please describe:When would you like to schedule? What month? Next available appointment? Do you have a preferred time or particular days? Is this an urgent request?Is this for... *your right eye?your left eye?both eyes?Would you like us to bill your insurance? *NoNo, I would like to self-pay and submit my own claim (this could save your the most money but it also requires more effort from you. Please research before you select this option.YesYes, but it's a Worker's Comp claimMaybe?What is your Worker's Comp information?Please provide the date of accident, claim number, adjuster's name, and phone number.It may be more cost effective to pay out of pocket for your services. We recommend checking your benefits with your insurance provider to tell you how much you've paid this year. Your insurance requires you to first pay a yearly deductible, then your co-insurance will kick in until you reach your out-of-pocket limit for the year (you are usually responsible for 20% of the charges after you completely pay your deductible amount). If you have a high deductible plan and do not anticipate medical expenses this year, it is likely better to not bill your insurance. If you pay for a premium insurance (low deductible) or had many hospital expenses this plan's year, you may have already met your deductible or out-of-pocket maximum, it is likey better to use your insurance for this service. We are not in-network with every insurance provider but we can usually set up a one-time contract to get the service you want covered at your in-network benefits. Expect 2-8 weeks to get this type of approval. Submitting you own claim will save you money but it will also require some work. Before your appointment, we recommend calling your insurance company to find out if there is a in-network provider for eye prosthetics. If there is not, you can request our service to be covered as an in-network benefit. Once you have that authorization number, you can schedule your appointment with us. At your appointment, we will charge a credit or debit card for the full amount. This can be an HSA card. With the receipt, you can submit it with your authorization letter and your insurer's self-claim/reimbursement form. In time, you should receive a reimbursment check. Insurance NameInsurance NumberPlease attach a photo of the FRONT of your insurance card Click or drag a file to this area to upload. Please attach a photo of the BACK of your insurance card Click or drag a file to this area to upload. Are you the insurance subscriber?YesNo (my spouse or parent is the subscriber)What is the subscriber's name (as listed on the card) and date of birth?Do you have a secondary or supplemental insurance? NoYesSecondary Insurance CompanySecondary Insurance NumberPlease attach a photo of the FRONT of your secondary insurance card Click or drag a file to this area to upload. Please attach a photo of the BACK of your secondary insurance card Click or drag a file to this area to upload. Are you the insurance subscriber?YesNo (my spouse or parent is the subscriber)What is the subscriber's name (as listed on the card) and date of birth?Please give me a concise history of your eye... when did you lose it and why? When was your most recent surgery? Will this be your first prosthesis or when was your first prosthesis? When was your most recent prosthesis? Who made your prosthesis? *Who referred you to us and/or who is your ophthalmologist? *Do you have a referral or clinic note to upload? Click or drag files to this area to upload. You can upload up to 3 files. CONSENT FOR TREATMENT AUTHORIZATION TO RELEASE INFORMATION FOR PAYMENT OF SERVICES I, the undersigned patient / responsible party consent to the medical procedures, treatments and examinations to be provided for the rendering of an artificial prosthesis and / or related services from this date forward. I, the undersigned patient / responsible party am responsible for supplying the necessary insurance and physician information in order for Custom DME to obtain a physician’s referral, as well as insurance authorization in order to proceed with the above mentioned services. I, the undersigned patient / responsible party acknowledge being given a copy of the Notice of Privacy Practices and understand the terms and conditions written therein. I, the undersigned patient / responsible party request that payment of authorized benefits be made on my behalf for any services furnished me by Custom DME, LLC. I authorize any holder of medical or other information about me (including but not limited to chart notes, photographs and/or models) which are obtained in connection with my treatment be released to the appropriate insurance agency and its agents as needed to determine these benefits or benefits related services. I permit a copy of this authorization to be used in place of the original. I, the undersigned patient / responsible party authorizes Custom DME, to disclose financial and medical information and records to: my employer and third party payers, who are or may be responsible for payment of all or a portion of the charges; to other health care accreditations, audits, certification, appeal councils, and peer or utilization reviews. Signed consent is given upon voluntary submission of the above information. *I Consent to the Treatment Authorization and Release of Information for Payment of ServicesSubmit