Any Questions please

ARMAC Authorization Dept.

Please fax to: 973-328-3753

call 888-422-3044

with a copy of your prescription.

Contact Name:

Date of Fax:

Please fill out all areas of this form.

Patient Name:

Date of Birth:

Address:

Male or Female:

City, State, Zip:

Home Number:

Cell Number:

Is the injury due to:(please circle one if applicable)

Prescribing Doctor:

Auto Accident

Dr.'s phone #:

Worker's Comp

For what side: Right or Left or Both (please circle one)

Other:

Product / Description:

Date of Injury:

Claim #:

Insurance Information:

Primary Insurance:

Primary Subscriber Name:

Relation to Patient:

Policy Number:

Subscribers Date of Birth:

Group#:

Type of Plan:

Claims Address / Phone Number:

Secondary Insurance:

Primary Subscriber Name:

Relation to Patient:

Policy Number:

Subscribers Date of Birth:

Group#:

Type of Plan:

Claims Address / Phone Number:

Diagnosis Code or Description:(should be on your prescription form doctor, if not please ask Dr. for DX Code)

Have you received products from ARMAC before?

Y or N

I authorize my physicain to release to ARMAC Inc and for  Armac to release to my insurer any needed information for this or a related claim.

Patient Signature:

Date:

********Please fax this form in along with a copy of your prescription from your doctor to 973-328-3753 ******