Collecting information from you
To simplify the funding process, our team works with you and your insurance to get you the device you need, with the lowest possible out-of-pocket cost.
We need to collect information from you, as part of this process (outlined in the Funding Roadmap) and there are a number of forms involved.
Below, you can access downloadable forms, or complete them online.
Forms
(Control Bio + Lincare + NuMotion)
Lifetime Release & Assignment of Benefits
ABN / Release Form (Control Bio)
Lifetime Release & Assignment of Benefits
ABN / Release Form (Lincare)
Lifetime Release & Assignment of Benefits
ABN / Release Form (NuMotion)
Lifetime Release & Assignment of Benefits
Authorization for Release Form
Authorization for Release of Media and/or Personally Identifiable Information
Client Information Form
Trial Contract Form
Control Bionics Trial Agreement
formulario de contrato de prueba
Acuerdo de Prueba de Control Bionics