EmailMeForm
Medicare Verification
Patient Name
*
First
Last
Medicare Claim Number
*
Part A Effective Date
*
MM
/
DD
/
YYYY
Client D.O.B.
*
MM
/
DD
/
YYYY
Client Zip Code(must be the zip code were benefits are registered)
*
Patient Phone Number
*
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Patient ID (Required)
*
Patient Medicare Card (Required)
*
Verify drivers license or ID is valid and not expired
Personal or family history of lung and skin cancer NOT used for CGx submission. These cancers are not eligible.
Patient not over the age of 75 (no age restrictions for braces and creams)
*
I Agree.
Agent Name
*
Agent Email
*
Agent Cell Phone
*
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