DME Product

Representative's Name

(First & Last Name)

Company Name

Phone

Email

Name of Item

Only one per form

Name of Manufacturer

Intended use or targeted providers

Sponsoring Physicians/Providers

Our Cost (We do not provide usage levels.)

CPT Tode

Can it be reimbursed?  Yes
No

Is there an option to have our logo on it?  Yes
No

If "yes" to above, is there any additional cost?  Yes
No

Recommended Reimbursement

Web link to product information

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