Neurostim Treatment Interest & Eligibility Form

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

Patient Information

First name

Last name

Birthday

Month

Day

Year

Phone

Address

Medical Eligibility

1. Do you have a diagnosis of diabetes?

Yes

2. Are you currently experiencing diabetic-related pain or neuropathy?

Yes

Insurance Information

3. Do you have Medicare Part B?

Yes

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.

Signature

Signature field is empty.

Date

Month

Day

Year