Patient and Insurance Information

If patient is currently under a surgical global period, please indicate date and procedure completed

Physician and Facility Information

Product and Treatment Information

15271 – 15274 for wounds on the trunks, arms, and/or legs
15275 – 15278 for wounds on the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits

Diabetic foot ulcer

Diabetic foot ulcer

Diabetic foot ulcer

Other

Please send form along with a copy of the front and back of patient’s insurance card
to sunderwood@prodatamgmt.com or fax to (866) 205-0732.

If further assistance is needed, please contact IVR Support Team at (919) 249-7293 for additional support.

Disclaimer: Legacy Medical offers insurance verification as an information service only. Information gathered during the requested research will be provided by the insurer or third-party
payer. Results of this research are not a guarantee of coverage or reimbursement in the future.􀀁􀀁Legacy Medical􀀁disclaim liability for payment of any claims, benefits, or costs.