Address where equipment will be used (if different from above): Period of time requested: MFGR MODEL/PRODUCT SINGLE UNIT AMT. PKG NUMBER PRICE $ $ $ $ $ Diagnosis and Present Physical Condition Prognosis Treatment Plan Expected Therapeutic Effect ATTACMENT C: HEALTH INSURANCE CLAIM FORM (SEE NEXT PAGE)
Address where equipment will be used (if different from above): Period of time requested: MFGR MODEL/PRODUCT NUMBER SINGLE UNIT PRICE AMT. PKG $ $ $ $ $ Diagnosis and Present Physical Condition Prognosis Treatment Plan Expected Therapeutic Effect ATTACMENT C: HEALTH INSURANCE CLAIM FORM (SEE NEXT PAGE)
EPSD-NEW-MANUAL-FINAL-01-01-18.docx