Documents and forms
Atos Medical is committed to helping you navigate through the insurance and reimbursement process to make it as smooth and easy as possible, getting the most from your benefits. We will file claims for durable medical equipment (DME) orders and are in-network with a variety of insurance companies (click here for the latest list).
For an insurance claim to be filed, we need the following*
- Patient Services Form
- Prescription Form
- Copies of ALL health insurance cards (front and back)
*The type of DME equipment ordered (laryngectomy or jaw motion rehabilitation supplies) will determine which forms need to be completed
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To use our secure link to submit any already completed form, follow these steps |
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- Click the upload icon to send documents directly from your computer or smartphone
- Enter your name and email address
- Include a short message for our team (optional)
- Click “Choose File” or drag documents, files or images into the box
- An onscreen confirmation message will let you know the documents have been submitted
Some of these materials are also available in Spanish and can be found here.
MC2345 Patient Services Book
- Important Patient and Privacy Information
- www.atosmedical.com
MC2346 Patient Services Form
- By signing, I acknowledge that I have received a copy of the above Patient Services Book which contains Patient Bill of Rights and Responsibilities, Patient Service Agreement, Notice of Privacy Practices (HIPAA), Ordering Laryngectomy Supplies and Understanding Your Insurance Benefits.
MC1753 Consent Form, English
- To help us provide great customer service and deliver our products directly to you, please complete and return
MC1724 Prescription Form, Laryngectomy
- Must be signed by treating prescriber
- Form is optimized for download and completion in Adobe Acrobat/Reader
- Acrobat Reader can be downloaded for free at get.adobe.com/reader
MC2378 Prescription Form - Jaw Motion Rehabilitation
- Must be completed by treating physician
AM0006 Medicare Compliance Form
- 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.
Medicare Provider Enrollment, Chain of Ownership System (PECOS)
- For any durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items to qualify for coverage by Medicare it must be ordered by a physician or a practitioner who is eligible to order such item.
AM0005 CMS Medicare DMEPOS Supplier Standards
- CMS Medicare DMEPOS Supplier Standards