The Importance of Home Use Referral

In the evolving landscape of inpatient and outpatient reimbursement, preparing your patients for community integration has never been more critical. Whether trained in Bioness technologies or not, you are part of the 9000+ Bioness clinician network working every day to improve patient outcomes.

Working together we have dramatically increased the percentage of successful patient reimbursement allowing more people the ability to continue their rehabilitation after discharge. Without a therapist referral, these patients would never have had the opportunity to learn about rehabilitation outside of the clinic setting.  Your day-to-day efforts are creating lifelong changes in functional independence and quality of life.

Referring a patient to us is as easy as 1, 2, 3!

1. Fill out the Form below and hit REFER. A printable Patient Information & Medical Release Form- Form 1 will automatically generate.

2. Have your patient sign the form.

3. Fax it to us at 877-362-4855.

YOU'RE DONE!

A Bioness Representative will contact you if there are any issues with your submission.

* Required Field

Type of Provider:
* Clinician Name (First & Last):
Clinician E-mail:
Clinician Phone:
Physician Name (First & Last):
* Patient First Name:
* Patient Last Name:
Patient Date of Birth: (m/d/yyyy)
Patient Phone:
Patient Street:
Patient City:
Patient State:
Patient ZIP Code:
Patient E-mail:
Do you practice at a Bioness Trained Facility?
Facility Where Patient Receives Therapy:
Facility Where Patient Receives Therapy:

Please fill in the Patient ZIP Code field
to load nearby facilities.

Consent:
Primary Diagnosis:
Products:

L300 Electrode Type:
Primary Insurance Name:
Comments/Notes: