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                   Stroke Recovery Systems, Inc.   
8100 South Park Way #A1 Littleton, CO 80120; Ph (800) 845-1771; Fax (800) 495-6695 www.neuromove.com 

          Physician's Statement of Medical Necessity for NeuroMove Therapy
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Patient Name ___________________________           SS# _________________________
Date of Birth  ___________________________           HIC# ________________________
________________________________________________________________
ICD-9 code(s) ___________________,    ___________________,    _________________                 

Conditions: ( Pls check all that apply)            
 __ Hemiplegia,   __ Muscle spasms present, __ Shoulder,  __  Elbow, __  Hand/fingers, __ Drop foot
Other specify: ____________________________________________________________

Primary Diagnosis:  _____ CVA                                 
Other specify: ____________________________________________________________                                                    
Affected side:   L  /  R  /  Both
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Est. Length of need (#of months): ________________ 1-99 (99=lifetime)
Treatment Objectives: ____________________________________________
                                        ____________________________________________

Physician's Name     ___________________________      UPIN#: ____________________

Office Telephone #: ___________________     Office Fax #:________________________
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I certify that AutoMove therapy is medically necessary for this patient and in my opinion reasonable with reference
to accepted standards of medical practice and treatment of this patient's condition.

PHYSICIAN'S SIGNATURE _____________________________________ DATE_______________________
(Signature and date stamps are not acceptable).
_________________________________________________________________

_________________________________________________________________
                        
                 Stroke Recovery Systems, Inc.   
8100 SouthPark Way A1, Littleton, CO 80120; Ph (800) 845-177;1 Fax (800) 495-6695 www.neuromove.com

                                      PATIENT INFORMATION FORM
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Date and Type of Unit Issued: ______________________                                             

Patient Name:_____________________________     SS# ________________________   
Address:        _____________________________     Date of Birth __________________
City: ______________, State _____, Zip_______     Phone# _______________________
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Primary Insurance: _________________________ Phone# _______________________
Address:        _____________________________    Policy#  __________________
City: ______________, State _____, Zip_______     

Patients relationship to insured: __Self, __Spouse, __Child, __Other

Secondary Insurance: _______________________ Phone# ______________________
Address:        _____________________________    Policy#  __________________
City: ______________, State _____, Zip_______     
_________________________________________________________________

Clinic: ________________________________ Phone# _______________________

Prescribing Physician: ________________________ Phone# _______________________
Address:  ________________________    City: _____________, State ____, Zip_______ 

Physical or Occupational Therapist: _____________________ Phone# _______________
Address:  ________________________    City: _____________, State ____, Zip_______

DO NOT ISSUE TO PATIENT WITH PACEMAKER
                                       PLEASE ENCLOSE COPY OF PRESCRIPTION
_________________________________________________________________
Office use only: Qty:____, Serial #:_____________, Description: __________________
                          Monthly rental fee: _____________, Purchase price: ________________
_________________________________________________________________
I understand that I will be responsible for the return of the Stroke Recovery Systems Inc.’s equipment and if for any reason I do not return the unit 
directly to Stroke Recovery Systems Inc., I agree to pay the rental or purchase price.
I authorize the release of any medical information necessary to process my claim and I agree to pay for all charges not covered
 by this authorization or otherwise not paid by my insurance company. I permit a copy of this authorization to be as valid as 
the original.

Patient’s Signature __________________________________________ Date______________

Insured’s Signature __________________________________________ Date______________
(if different from patient)
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