Forms and Charts

FORMS AND CHARTS

To ensure a Precision TENS 3900 patient has sufficient supplies to follow the prescribed treatment regimen, GEMS will provide these supplies when the patient is referred to GEMS by their physician.  In order to provide a patient with TENS supplies, the following “Patient Intake Form” and “Prescription / Certificate of Medical Necessity” must be filled out, signed and dated.  Below, you will find a copy of the “Prescription / Certificate of Medical Necessity” and the “Patient Intake Form.”  Both can be filled out on your computer, then printed.

Insurance Verification Form for Physicians

Patient Intake Form

Prescription/Certificate of Medical Necessity