_________________________________________________________________ Zynex Medical 8022 Southpark Circle Littleton, CO 80120; Ph (800) 845-1771; Fax (800) 495-6695 www.neuromove.com Physician's Statement of Medical Necessity for NeuroMove Therapy_________________________________________________________________
Patient Name ___________________________ SS# _________________________Date of Birth ___________________________ Policy# _______________________ Date of Incident: _________________ICD-9 code(s) ___________________, ___________________, _____________ Conditions: ( Pls check all that apply) __ Hemiplegia, __ Muscle spasms present, __ Shoulder, __ Elbow, __ Hand/fingers, __ Drop foot
__ Paraplegia __ Quadraplegia
Other specify: ____________________________________________________________Primary Diagnosis: _____ CVA ____ SCI Other specify: ____________________________________________________________ Affected side: L / R / Both_________________________________________________________________Est. Length of need (#of months): ________________ 1-99 (99=lifetime)Treatment Objectives: ____________________________________________ ____________________________________________Physician's Name ___________________________ UPIN#:________________Office Telephone #: ___________________ Office Fax#:________________________________________________________________________________________I certify that NeuroMove therapy is medically necessary for this patient and in my opinion reasonable with referenceto accepted standards of medical practice and treatment of this patient's condition.
PHYSICIAN'S SIGNATURE _____________________________________ DATE_______________________(Signature and date stamps are not acceptable).
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Date of Incident: ______________________ Patient Name:_____________________________ SS#_______________________ Address: _____________________________ Date of Birth _______________City: ______________, State _____, Zip_______ Phone#_______________________________________________________________________________________Primary Insurance: _________________________ Phone#_______________________Address: _____________________________ Policy# __________________City: ______________, State _____, Zip_______ Patients relationship to insured: __Self, __Spouse, __Child, __OtherSecondary 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 PACEMAKERPLEASE ENCLOSE COPY OF PRESCRIPTION AND INSURANCE CARD_________________________________________________________________Office use only: Qty:____, Serial #:_____________, Description: __________________ Monthly rental fee: _____________, Purchase price: _________________________________________________________________________________I understand that I will be responsible for the return of the Zynex Medical equipment and if for any reason I do not return the unit directly to Zynex Medical, 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)_________________________________________________________________
Authorization for Automatic Credit Card Charge
I hereby authorize Zynex Medical to initiate a first payment and automatic monthly charges if required to my Visa or MasterCard according to the lease contract. I have read and agree to the lease terms and conditions.
I have chosen the following Lease-to-Own plan:
[ ] 1. Three initial monthly payments of $165.00 ($99 x 3 months + $198 down payment)Then only $99.00 per month for 55 months
[ ] 2. Initial payment of $495.00 ($99 x 3 months + $198 down payment)Then only $99.00 per month for 55 months
[ ] 3. Initial payment of $996.00 ($198 x 2 months + $600 down payment)Then only $198.00 for 25 months
[ ] 4. One time cash payment option: The price for the NeuroMove 900™ is $5950.00.If you choose this option, a 15% discount is offered, your total one time payment will be $5057.50
This authority will remain in full force and effect until I notify Stroke Recovery Systems, Inc. in writing to cancel it in such time as to afford the company a reasonable opportunity to act on it.
Please type or print the following:
Name: ___________________________________________________________________
Address:______________________________________________________________________
City: _____________________________________________ State: _____ Zip: ___________
Credit Card Number: ________________________________________________________
Expiration Date: ______________________
Signature: ________________________________________ Date: ______/______/______
Zynex Medical - Stroke Recovery Systems, 8022 Southpark Circle, Littleton CO 80120
Fax: 1-800-495-6695
About the Lease to Own Program:The Lease to Own Program we offer provides different payment options to choose from. It provides the opportunity to return the NeuroMove if you are not satisfied - you are not locked into a long-term contract. It also provides an opportunity to own the NeuroMove at the end of the lease period.
You may return the unit at any time; however, you may convert to an outright purchase at any time, with a discount for doing so. When you pay the Lease off early or make all of your payments as scheduled, the NeuroMove will be considered paid in full and your property. The NeuroMove comes will all accessories and electrodes needed for the prepaid period. It may be required for you to purchase additional electrodes if you decide to keep the device for a longer period of time.
If the NeuroMove unit is returned, the down payment and monthly payments will be retained by Zynex Medical.
The list price of the NeuroMove is $5,950.00. Your insurance plan may be billed for the full purchase price or $498.00 monthly for the use and payments from insurance may give you the option of additional use or a refund. To give you a chance to get started with the NeuroMove, we offer the following Lease-to-Own Programs:
Terms & Conditions
I hereby authorize Stroke Recovery Systems (SRS) and Zynex Medical to charge my VISA or MasterCard for the use and Lease of the NeuroMove device as per the lease option chosen. I also authorize Zynex to keep charging my credit card for every month commenced until the NeuroMove is returned to Zynex or the device purchased. If I decide to return it to Zynex, I am not liable for any further payments. Refunds cannot be given on disposable medical supplies (electrodes); down payment and any monthly payments will be retained by Zynex Medical, if the Lease is cancelled prematurely by either your returning the unit or by failing to honor the terms of the Lease. The NeuroMove is a medical product requiring a doctor's prescription. At no time during lease period or if it is purchased may it be loaned or resold. FDA REGULATIONS MUST BE COMPLIED WITH.
1. ACCEPTANCE OF EQUIPMENT - The lessee shall inspect the equipment delivered pursuant to this Agreement. The Lessee shall immediately notify SRS of any discrepancies between such item of equipment and the description of the equipment in the Equipment Schedule. If the Lessee fails to provide such notice in writing within 7day(s) after the delivery of the equipment, the Lessee will be conclusively presumed to have accepted the equipment as specified in the Equipment Schedule.
2. OWNERSHIP AND STATUS OF EQUIPMENT - The equipment will be deemed to be personal property, regardless of the manner in which it may be attached to any other property. Zynex shall be deemed to have retained title to the equipment at all times, unless SRS transfers the title by sale at the end of this lease term. The Lessee shall immediately advise Zynex regarding any notice of any claim, levy, lien, or legal process issued against the equipment.
3. PAYMENTS FROM INSURANCE COMPANIES - Any payments from insurance on the Lessee's behalf are payable directly to Zynex Medical and applied to the total purchase price of the unit. If Lessee opts to return the unit before full payoff has been met, Lessee is not entitled to a refund of monies collected from insurance to date. Zynex Medical will refund any amount that exceeds the total payoff.
4. INDEMNITY OF SRSI FOR LOSS OR DAMAGES - If the equipment is damaged or lost, Zynex shall have the option of requiring the Lessee to repair the equipment to a state of good working order, or replace the equipment with like equipment in good repair, which equipment shall become the property of SRS and subject to this Agreement. The Lessee shall pay the full purchase price of the device in such case and Zynex shall provide replacement equipment if the Lessee continues to lease.
5. LIABILITY AND INDEMNITY - Liability for injury, disability, and death of workers and other persons caused by operation, handling, or transporting the equipment during the term of this Agreement is the obligation of the Lessee, and the Lessee shall indemnify and hold Zynex harmless from and against all such liability.
6. DEFAULT - The occurrence of any of the following shall constitute a default under this Agreement:A. The failure to make a required payment under this Agreement when due.B. The violation of any other provision or requirement that is not corrected within 20 day(s) after written notice of the violation is given.C. The insolvency or bankruptcy of the Lessee.D. The subjection of any of Lessee's property to any levy, seizure, assignment, application or sale for or by any editor or government agency.
7. RIGHTS ON DEFAULT If the Lessee is in default under this Agreement, without notice to or demand on the Lessee, Zynex may take possession of the equipment as provided by law, deduct the costs of recovery (including attorney and legal costs), repair, and related costs, and hold the Lessee responsible for any deficiency. Zynex shall be obligated to release the equipment, or otherwise mitigate the damages from the default, only as required by law.
8. NOTICE - All notices required or permitted under this Agreement shall be deemed delivered when delivered in person or by mail, postage prepaid, addressed to the appropriate party at the address shown for that party at the beginning of this Agreement.
9. ASSIGNMENT - The Lessee shall not assign or sublet any interest in this Agreement or the equipment or permit the equipment to be used by anyone other than the Lessee or relevant healthcare professionals, without Zynex's prior written consent.
10. ENTIRE AGREEMENT AND MODIFICATION - This Agreement constitutes the entire agreement between the parties. No modification or amendment of this Agreement shall be effective unless in writing and signed by both parties. This Agreement replaces any and all prior agreements between the parties.\
11. GOVERNING LAW - This Agreement shall be construed in accordance with the laws of the State of Colorado.
12. SEVERABILITY - If any portion of this Agreement shall be held to be invalid or unenforceable for any reason, the remaining provision shall continue to be valid and enforceable. If a court finds that any provision of this Agreement is invalid or unenforceable, but that by limiting such provision, it would become valid and enforceable, then such provision shall be deemed to be written, construed, and enforced as so limited.
13. WAIVER - The failure of either party to enforce any provision of this Agreement shall not be construed as a waiver or limitation of that party's right to subsequently enforce and compel strict compliance withevery provision of this Agreement.
14. MAINTENANCE AND REPAIR - The Lessee shall maintain the equipment in good repair and operation condition, allowing for reasonable wear and tear. The Lessee shall pay all costs required to maintain the equipment in good operating condition. Such costs shall include labor, material, parts, and similar items. Maintenance and alterations must be taken care of by SRS.
15. CARE AND OPERATION OF EQUIPMENT - The equipment may only be used and operated in a careful and proper manner and according to the Users Manual. Its use must comply with all laws, ordinances, and regulations relating to the possession, use, or maintenance of the equipment.
16. ALTERATIONS - Lessee shall make no alterations to the equipment without prior consent of SRS. All alterations shall be the property of Zynex and subject to the terms of this Agreement.
17. RISK OF LOSS OR DAMAGE - The Lessee assumes all risks of loss or damage to the equipment from any cause, and agrees to return it to the Zynex in the condition received from Zynex, with the exception of normal wear and tear.
American Stroke Foundation
Resource Site
International Functional Electrical Stimulation Society
American Physical Therapy Association
Stroke Journal
Neurology Stroke Information
Useful Stroke Information
