Customer Information Form
(800) 950-6020 – (314) 821-7355
Please provide the requested information necessary for us to submit claims to your insurance company on your behalf. An
asterisk (*) denotes required information.
In addition to this form, some products purchased require a Certificate of Medical Necessity or a prescription to be completed by
your physician before claims can be filed. Please call us if you are unsure if the product you are purchasing requires this.
SIGNATURE ON FILE AGREEMENT
*Patient Name: Acct. #:
*Address: Date of Birth:
*City, State, ZIP: Sex: M F
*Contact Person (if other than patient) Contact Phone:
*Ordering Doctor’s Name:
*City: State: Zip:
Physician License #: _____________________ Verified Date: ________________ License Exp Date: _________________
Enrolled into PECOS: Yes No Date Verified: ______________________
PRIMARY INSURANCE SECONDARY INSURANCE
*City: *State: *ZIP: *City: *State: *ZIP:
*ID #: *ID #:
*Group #: *Group #:
Your signature below signifies your understanding that your insurance company (Medicare or private insurance) may not cover the items
you purchased or may not cover them at 100%. Nextra Health cannot guarantee coverage or reimbursement amounts on any item
purchased. You may be responsible for any charges not covered by your insurance policy. A service charge of 1-1/8% per month 18% APR
will be added to all overdue accounts. You are also liable for all legal and collection fees.
I request that payment of authorized medical benefits be made for any products furnished to me by Nextra Health. These payments are
to me, or on my behalf, to Nextra Health.
ent’s Signature: *Date:
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