Documents and forms

Atos Medical is committed to helping you navigate through the insurance and reimbursement process to make it as smooth and easy as possible, getting the most from your benefits. We will file claims for durable medical equipment (DME) orders and are in-network with a variety of insurance companies (click here for the latest list).

For an insurance claim to be filed, we need the following*

  • Patient services form
  • Prescription form
  • Copies of all health insurance cards (front and back)

*The type of DME equipment ordered (laryngectomy or jaw motion rehabilitation supplies) will determine which forms need to be completed

To use our secure link to submit any already completed form, follow these steps:

  • Click the button to the right to send documents directly from your computer or smartphone
  • Enter your name and email address
  • Include a short message for our team (optional)
  • Click “Choose File” or drag documents, files or images into the box
  • An onscreen confirmation message will let you know the documents have been submitted

Some of these materials are also available in Spanish and can be found here.



Click to upload

View document

MC1724 Prescription Form, Laryngectomy

Helpful tips when filling out the Prescription Form:

  • Download the file to your computer and open with a PDF viewer for full form functionality
  • Free PDF viewer can be downloaded from Adode here
  • For items with multiple types and/or sizes (e.g. VP, LaryTube, FlexiVoice) all these distinctions are required
  • Phone number format must match: (123) 123-1234