Patient Cold Therapy/CPM

Park Avenue Orthotics, Inc.

155 E 55th Street, Suite 200, New York, NY 10022
Prescribed Equipment*

Game Ready RentalNICE1 RentalCPM RentalKinetec Cryo ProBreg Polar Care CubePlasmaFlow DVT ProphylaxisOther
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Patient Name*

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DELIVERY RECEIPT AND ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)

NOTE: Insurance providers do not pay for everything, even for some care that you or your health care provider have good reason to think you need. Cold therapy is not covered by most insurance carriers.

WHAT YOU NEED TO DO NOW: Please read the above ABN notice and ask us any questions that you may have so you can make an informed decision about your care. Then please select one of the two options below about whether to receive the item.
Check Only One Box*

OPTION 1: I want the item(s) listed above. I understand that I am responsible for payment. I cannot appeal if my insurance carrier is not billed.OPTION 2: I do not want the item(s) listed above. I understand with this choice I am not responsible for payment.
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