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Insurance & Workers’ Comp
Restore You Therapeutic Support may qualify under select insurance and workers’ compensation plans. Print the prescription form and take it to your doctor’s office for signature before submitting it to your specific insurance company.
One page. Prints on standard letter paper.
Download the prescription form and fill in your name and date of birth.
Bring it to your surgeon or doctor. They add their name, NPI, phone number, signature and the date.
Send the signed form with your receipt to your insurance company or workers’ comp claim, following their instructions.
It depends on your plan. Some insurance and workers’ compensation plans reimburse for it, and others don’t. Call your insurance company or claims adjuster to ask what they need before you submit.
No. Surgical Recovery Systems doesn’t file claims or work with insurance companies directly. You buy Restore You, then submit the signed form and your receipt to your plan for reimbursement.
E0190 is the equipment code for a positioning cushion, pillow or wedge. Insurance companies use it to identify the item you’re asking them to reimburse. It’s already printed on the form.
Restore You is HSA/FSA eligible. If your plan administrator asks for a letter of medical necessity, a signed copy of this form may help.
The doctor treating you, usually the surgeon who performed your procedure. Their NPI (National Provider Identifier) number is on file at their office.
Restore You is $199 with free standard shipping in the U.S. Questions? Contact us.
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