Additional Information Request
Thank you for booking an appointment with Second Silhouette/Women's Health Boutique. We look forward to seeing you! If you are planning on having us check on and or file with your insurance provider, please complete the following information. In order for us to file for you, we will need to have this information well before your appointment with us.

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We do our best to verify benefits accurately, however it is ultimately your responsibility to take care of any financial responsibility not covered by your insurance plan. We strongly recommend you understand your specific plan's coverage on DME products (Durable Medical Equipment).

Name (exactly as shown on your insurance card) *
Your answer
Date of Birth *
Your answer
Address 1 *
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Address 2
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City *
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State *
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Zip *
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Phone Number *
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Email
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Insurance Provider *
Your answer
Policy or Member ID (not group number) *
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Secondary Insurance Policy #
Your answer
If a Medicare Supplement, please indicate which Plan, i.e.: Plan C, Plan F, etc
Your answer
Secondary Insurance (if applicable)
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Referring Doctor
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Referring Doctor Phone
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Diagnosis
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We cannot file with your insurance without a current prescription (must be dated within the past year). You may have the doctor fax your prescription to our electronic fax at 713-456-2188.
I acknowledge that Women's Health Boutique/Second Silhouette will not be able to provide products under my insurance without a current prescription. I will pay out of pocket for any items I do not have a prescription for. *
Required
Products Interest *
Comment
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