🧾 DFW Therapy Rentals – Reimbursement Request Form

  we provide reimbursement documentation for you to submit to your insurance company. The documentation you need is below:

A Letter of Medical Necessity for your doctor to complete

Your final itemized receipt

Both documents will have the device insurance billing code your insurance company needs for processing your reimbursement

The Letter of Medical Necessity (LMN) below is provided by our company at the time your order is placed and may be required by insurance to authorize payment for Durable Medical Equipment or other medical services. This form allows your doctor to provide everything your insurance company requires and includes our device’s billing code.

You must submit the completed and signed by your doctor, along with your rental or purchase receipt to your insurance company