Physician Insurance Intake Form


Please fill in the form

Click here to review and download .pdfs of the Billing Service Recipient Bill of Rights and Responsibilities, DME POS Supplier Standards, release of information, Notice of Privacy Practices and Billing Service description

Please complete the form below to initiate the insurance submission process for your patient's bone anchored hearing system (Sentio™ or Ponto™).

Important:
In addition to this form, patients will need to submit the following. Please note we cannot begin working on a request until all paperwork has been received:  
- Completed Patient Submission form
- Relevant clinical notes and a Letter of Medical Necessity (LMN)
- Front and back copies of patient's insurance card, which can be emailed to InsuranceServices@oticonmedical.com or faxed to 888-683-8736 
(NOTE: Fields with a red * below are required)

Our dedicated insurance services team is here to assist you in ensuring timely and accurate claim submissions. If you have any questions, please contact us at the email above anytime or call 855-400-9761 (Mon-Fri 8am-5pm ET).

Physician Information
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Audiologist Information
Service request
Request
Model Qty.
Colors
Color of processor
Free Accessory
Please choose ONE for unilateral patient or TWO for bilateral
Softband 5
Please choose
Procedures Information
Place of service
Side of implant
Medical Information
Patient Information
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