PARI Nebulizer Cup Order Form

Your Information
Patient First Name*
Patient Last Name*
Parent / Guardian First Name
Parent / Guardian Last Name
Street Address*
Apt./Unit
City*
State*
ZIP Code*
Email*
Phone*
Physician's Practice or Clinic Name*
Prescribing Physician Name*
Clinic Phone Number*
Physician Fax Number
Insurance Information
Insurance Type*
Member ID (Letters & Numbers)*
Insurance Phone Number*
Please Read and Sign
- I understand that Neb Doctors of Maryland, LLC or its assignee (“Provider”) is independently owned and operated and is not in any way associated with a hospital, medical practice or any other clinic.
- I certify that the information provided by me and applying for payment under title XVIII (Medicare) of the Social Security Act of any other insurance benefits is true and correct.
- I understand that if my insurance coverage is denied, I am responsible to pay Provider the usual and customary amount/ price for this equipment.
- I authorize release of all medical records needed in relation to the above referenced equipment.
- I request that a payment be made to Provider by my insurance company, Medicaid, Medicare or government benefits.
Please check box to agree:*
- I certify that I have read the terms and conditions of this agreement, any attachments and agree to its content.

Purchase Option

Purchase the Nebulizer Cup and tubing for $24.95 and shipping is FREE!

Privacy Policy

Neb Doctors of Maryland is committed to protecting your online privacy. All information you supply is for our internal review only. It will never be shared or sold to any other organization or used for any other purposes.

Requests may be placed online, or over the phone. If you have any questions before requesting your respiratory equipment, please call us at 866-643-4020

PARI Nebulizer Cup Order Form

PARI Nebulizer Cup Order Form

Your Information

Insurance Information

Please Read and Sign

Purchase Option

Privacy Policy

Qualify Through Insurance

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