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Insurance Forms for Lymphedema Treatments

Let’s get started! First, we need some information from you. This will allow us to verify your insurance benefits and determine how we can best help. Please send your completed form(s) via fax or email to:

1.866.435.3949 or

A Tactile Medical representative will be in touch with you soon thereafter.

Patient Information Form

This allows us to gather the necessary information to verify your insurance benefits.

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Patient Consent Form

This initiates the order process and is necessary to contact you to determine next steps.

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Patient Assistance Consideration Application

The information provided helps to determine eligibility for when financial assistance is needed in obtaining a Tactile Medical product(s).

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E0651 Medicare Coverage

Downloadable documentation to ensure Medicare Coverage Criteria is met when ordering an Entre system.

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E0652 Medicare Coverage

Downloadable documentation checklist to ensure all Medicare Coverage Criteria is met in patient medical records when ordering a Flexitouch system.

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