CES Ultra Prescription Form

Cranial electrotherapy stimulator (CES Ultra): Unspecified Medical equipment E1399, with

electrodes E1399, supplies A4556, education 99241

Physician/Healthcare Provider: Name____________________________ DEA# _________

Address: _____________________________________

City: _____________________________________ State: ________ Zip: ____________

Telephone: _____________________________ Fax: _____________________________

Patient name: _________________________________________

Address: _____________________________________

City: _____________________________________ State: ________ Zip: ____________

Medical Necessity:

For ____ Anxiety (ICD-9300); _____ Depression (ICD-9311); _____ Insomnia (ICD-9370)

Dispense as written

Signature: _____________________________________ Date: ________________

CES Ultra Prescription Form

This form will be enclosed with your order.  Please return it in the enclosed envelope.  Thank you.

$300

Insurance Information: The CES Ultra is not usually covered by most Medical insurance. Some insurance companies will, however, provide reimbursement for the device (E1399) with a medical order and certification of necessity. Supplies (A4556) will usually be covered without additional medical orders or certification. Some will only consider rental.

I am NOT an insurance provider and will NOT file insurance for you.