Fax Form: Vendor Summary & Program Price-Matching Agreement

Please sign and return this agreement within one (1) business day.

Attention:

From:

Vendor:

Company:

Phone/Fax

Phone/Fax:

Enter all relevant information into fields below. All fields above will then be automatically filled-in for use as a 'Fax Form'.

Fax this form along with the 'Savings Calculator' for vendor to match all program terms and pricing.

Vendor Company

Vendor Contact

Vendor Phone

Vendor Fax

Vendor Email

Contact Date

Model Name

Description

Claimant Name

Claimant Phone

Claim Number

Date of Injury

Physician Name

Practice Name

Physician Phone

Physician Fax

Physician Email

Rx Date

If a device was fit prior to authorization, fill in the delivery date field. Also type in device type, number of channels, etc.

Date of Delivery

Device Type

Therapist Name

Clinic Name

Therapist Phone

Therapist Fax

Therapist Email

Case Manager

Company Name

CM Phone

CM Fax

CM Email

Calculator Estimates

Cost estimates per your company are

higher than FreeDME.com.

Device Program To Be Matched

Please select one option from this drop-down list... $ 485.00 TENS/EMS TwinStim II Program (w/1 Year Supplies) $ 860.00 TENS/EMS TwinStim II Program (w/2 Years Supplies) $1235.00 TENS/EMS TwinStim II Program (w/3 Years Supplies) $ 585.00 TENS/EMS TwinStim Plus II Program (w/1 Year Supplies) $ 960.00 TENS/EMS TwinStim Plus II Program (w/2 Years Supplies) $1335.00 TENS/EMS TwinStim Plus II Program (w/3 Years Supplies) $ 685.00 4-Channel QuadStar II IFC/EMS/TENS (w/1 Year Supplies) $1060.00 4-Channel QuadStar II IFC/EMS/TENS (w/2 Years Supplies) $1435.00 4-Channel QuadStar II IFC/EMS/TENS (w/3 Years Supplies) $1285.00 4-Channel QuadStar Elite IFC/EMS/TENS + HVG (w/1 Year Supplies) $1660.00 4-Channel QuadStar Elite IFC/EMS/TENS + HVG (w/2 Years Supplies) $2035.00 4-Channel QuadStar Elite IFC/EMS/TENS + HVG (w/3 Years Supplies) $ 685.00 Sterling HVG Program (w/1 Years Supplies) $1060.00 Sterling HVG Program (w/2 Years Supplies) $1435.00 Sterling HVG Program (w/3 Years Supplies) $ 375.00 TENS Supplies Package (As defined by attached form)

Please Note: We have the following www.FreeDME.com programs available to us. These programs include device purchase and a comprehensive and extensive TENS supplies and accessories package. Please view the programs at www.FreeDME.com for complete details. Included with this form is a 'Savings Calculator' print out comparing your charges for a similar device (and TENS supplies and accessories package) compared to the program prices from www.FreeDME.com. If you would like to service this claim you must match this program in its entirety and total charges. You must also agree to match the annual supportive care TENS supplies package at $375.00. All programs include: digital, multi-function device purchase, (52) electrode packs, (4) Vitamin E TENS Lotions 12 oz., (4) Pre-TENS Conductive Skin Preps, (4) Conductive Gel Tubes, (4) TAC GEL Tubes, (8) Standard Lead Wires (Device Specific), Energizer Multi-Battery Charger, (2) Complete (Device Specific) Energizer Rechargeable Battery Sets, Device Case, and a Portable Travel-Fanny Pack.

Our company agrees to match this 'www.FreeDME.com' program in its entirety and will not expect or demand payment until the arrival and contents of our package have been verified by the receiving patient.

Authorized Vendor Signature

Printed Name/Title

Date:

Our company is unable to match the (pricing, quality, complete product line and quantities) included in the electrotherapy device program listed and available to you from www.FreeDME.com. We hereby relinquish any and all interest in the above claim regarding electrotherapy including future TENS supplies and TENS accessories. We understand that if the device has previously been purchased, we will not attempt to pick up the device. If we pick up the device, we will return the purchase balance immediately.

We will pick up any equipment that was delivered prior to authorization with no financial obligation to the claim.

Authorized Vendor Signature

Printed Name/Title

Date:

The information contained in this facsimile message is medically privileged and confidential information intended for the use of the individual or entity named above. If you have received this facsimile in error, please notify the sender by telephone and destroy this message. Any dissemination, distribution or unauthorized use is strictly prohibited.