Patient paperwork
New patient forms
Everything a new patient needs to fill out, in one place. Start with the forms in Start here — those apply to everyone. The rest depend on what you are being fitted for and how you are paying. If you are not sure which ones apply to you, call us and we will tell you exactly what to send.
Questions? Call 800-883-1549 or text (517) 657-5223
Getting them back to us
Three ways to send your forms in
Most of these are fillable PDFs — you can type into them, save, and send the file back without printing anything.
Fax
800-886-4201
The fastest route if your provider’s office is sending them for you.
Bring them in
8988 East D Avenue, Richland, MI 49083
Mon–Wed 9–3 · Thu 9–5 · Fri 9–1
The forms
What to fill out
Every form below opens as a download. Nothing here has to be filled out perfectly — send us what you can and we will follow up on anything missing.
Start here
Every new patient fills out these, whatever you are being fitted for.
Take these to your provider
Your prescriber fills these out and signs them. Nothing can be ordered without one, so this is the piece worth chasing first.
Insurance and cost
Checking your benefit is free and carries no obligation. These explain what is covered, what is not, and what you would owe.
Pump trials and loaner equipment
If we are lending you a pump to try at home before anything is ordered, these two come with it. There is no charge for a trial and no obligation to order afterwards.
Our policies
How we handle your health information, and how to raise a concern if something goes wrong.
Worth reading
Not forms — background on the Lymphedema Treatment Act and on what we do.
Custom garment fittings are scheduled once your paperwork is in place. A custom fitting takes real time, so before we book one we need your prescription and provider documentation on file and your insurance benefit verified. Send the paperwork first — we will confirm your coverage and then call you to set a time.
Please do not send medical records or personal health information through the website contact form. Use fax, email or bring your paperwork in. If you would rather not put anything in writing, call us and we will take it over the phone.
Next steps
Once your forms are in
We verify your benefit, confirm what you owe before anything is ordered, and call you to arrange fitting or delivery. If something is missing we chase it with your provider’s office rather than sending you back and forth.