VIRTUAL TRAINER
ALL MUSCLE STIMULATORS
STARTER UNITS
MEDIUM UNITS
PROFESSIONAL UNITS
TENS UNITS
EMS AND TENS ACCESSORIES
FACIAL TONERS - WRINKLE REDUCTION
FEATURED UNIT
CONSULTATION
NEW PRODUCTS
EMS INFORMATION
TESTIMONIALS
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MUSCLE STIMULATORS
TENS UNITS
MENS HEALTH
WOMANS HEALTH
NUTRITIONAL PRODUCTS
LIFECOACHING AND FITNESS TRAINING
BODY FAT REDUCING GELS
SPECIAL DEALS!!
FEATURED PRODUCTS
SHIPPING
DETOXIFY YOUR LIFE
CONSULTATION
NEW PRODUCTS
PAIN RELIEF
PHYSIOTHERAPY

Insurance Form

In most cases, insurance companies will pay 80%-100% of costs for a TENS or EMS unit and/or monthly electrodes and supplies. Please complete the insurance verification form below, all information is sent via secure server. We will verify your insurance coverage and contact you within seven business days regarding your approval.

I would like coverage for: TENS Unit  EMS Unit
Would you like monthly supplies?  Yes   No   

Will you be using unit for pain relief?  Yes   No


PATIENT NAME:

HOME PHONE:  -   (Area Code plus the Phone Number)

EMAIL:

EMPLOYER:

Is your insurance through your employer?  Yes   No   
WORK PHONE:   -  (Area Code plus the Phone Number)
Extension: 

DATE OF BIRTH: 

SOC.INS/SEC#: OF PATIENT: 

ADDRESS: 

CITY: 
STATE / PROV:  ZIP / POSTALCODE: 

PHYSICIAN NAME:

PHONE:  -

ADDRESS: 

CITY: 
STATE:  ZIP CODE: 
Do you have a prescription:  Yes   No   
(If NO, one needs to be obtained) can you obtain one:
Yes   No   

What kind of coverage plan do you have?
We do not accept Medicare or Medicaid.
Worker Compensation :  Yes   No   

PRIMARY INSURANCE CO. OR MCO NAME: 

PHONE:  -   (Area Code plus the Phone Number)

POLICY/GROUP OR CLAIM #: 

SOC  INS /.SEC#: OF INSURED: 

PATIENT:  

NAME OF INSURED:

D.O.B. OF INSURED:  
EMPLOYER OF INSURED:  
RELATIONSHIP TO PATIENT: 


Assignment of Insurance Benefits
I hereby Authorize payment of medical benefits to Toneatronic for services furnished. I further authorize the release of any medical information required to process an insurance claim on my behalf. I permit a copy of this authorization to be as valid as the original.
EMS Information
  ->FAQ
  ->Unit Specifications
  ->What Is EMS?
  ->Is EMS Safe to use?
  ->Back Pain Relief
  ->Pad Placements
  ->EMS vs. Ab Belts
  ->Benefits
  ->Our Program
  ->Price Match
  ->Manuals & Video's
  ->Studies

TENS Information
  ->What is TENS?
  ->TENS Tips
  ->TENS Pad Placements
  ->TENS Skin Care

Insurance Coverage
 ->Insurance Page
 ->Insurance form

Clinical Tests

Testimonials