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(828)707-7112

Neurostim Treatment Interest & Eligibility Form

Thank you for your interest in Neurostim treatment. Please complete the form below to verify your eligibility.

Patient Information

Birthday
Month
Day
Year

Medical Eligibility

1. Do you have a diagnosis of diabetes?
Yes
No
2. Are you currently experiencing diabetic-related pain or neuropathy?
Yes
No

Insurance Information

3. Do you have Medicare Part B?
Yes
No
4. Which type of Medicare Part B coverage do you have?
Traditional (Straight) Medicare Part B
Medicare Advantage Plan (Medicare Part C)

Notice for Medicare Advantage Plan Holders Thank you for your interest in Neurostim treatment.

Based on the information provided, If you have a Medicare Advantage (Part C) plan.

Please be advised that Medicare Advantage plans may not cover this treatment. If you wish to proceed, a consultation fee will apply, and a full financial disclosure will be provided before any services are rendered.

By signing below, you acknowledge that:

  • Your Medicare Advantage plan may not cover Neurostim treatment.

  • You may be responsible for out-of-pocket costs.

  • A financial consultation will be provided to review any potential expenses before proceeding.


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Date
Month
Day
Year

CHRIS BOYHAN

Revolutionary technology that actually helps you heal. The vagal nerve stimulator for diabetic neuropathy and host of other indications is a game changer.

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JAKE COOPER

This place is outstandin. Great people and very professional and make you feel comfortable. Would highly recommend.

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CHERYL SCHOSKY

Mary Ellen always gives her undivided and personalized attention to important details. I highly recommend this place.

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SONJA MORACA

I’ve been getting salt facials with Mary Ellen and my skin has never been more glowy! Each treatment leaves me completely relaxed and more confident to be makeup free in my 52 year old skin!

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