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© 2010 General Medical Co. |
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(Please Print) FAX (310) 826-5778
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Name 
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Address Apt.
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City, State, Zip
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Country
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Note: Your country may add customs duties and taxes as well as other charges.
Additional charges imposed by British Government and EU Countries:
Customs duties and taxes plus administrative fee for customs clearance.
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Telephone
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E-mail
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Please send the following:
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Visa/MasterCard# Exp. date:
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Signature
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(cardholder)
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Send Check/Money Order and this form to:
General Medical Co. Dept. WWW-4
1935 Armacost Ave.
Los Angeles, CA 90025-5296
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MasterCard or Visa only
1-800-HEAL DOC or 1-800-432-5362
(310) 820-5881 (outside U.S.A.)
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HEALTH PLAN REIMBURSEMENT
The Drionic device is
reimbursable by many
health plans. If you wish
to submit a claim to your
health plan for reimbursement you
will need
a prescription from your
doctor, primarily a dermatologist.
There are two
ways to obtain Drionic
under a health plan:
1. Send payment with
order for immediate
purchase and file claim for
later reimbursement
from your health plan.
2. Obtain preauthorization from your health plan for purchase of
Drionic. When you receive authorization from your health plan indicating
that they will cover purchase, then send us your complete payment.
You then know that you will be reimbursed by your plan.
Codes needed by
insurance company:
CPT = E1399
ICD-9 = 705.21
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