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CES Ultra Prescription Form Cranial electrotherapy stimulator (CES Ultra): Unspecified Medical equipment E1399, with electrodes E1399, supplies A4556, education 99241 Physician/Healthcare Provider: Name____________________________ DEA# _________ Address: _____________________________________ City: _____________________________________ State: ________ Zip: ____________ Telephone: _____________________________ Fax: _____________________________ Patient name: _________________________________________ Address: _____________________________________ City: _____________________________________ State: ________ Zip: ____________ Medical Necessity: For ____ Anxiety (ICD-9300); _____ Depression (ICD-9311); _____ Insomnia (ICD-9370) Dispense as written Signature: _____________________________________ Date: ________________ CES Ultra Prescription Form Print out this form and mail it to Maryann Kaczmarek, 2856 S. Full Moon Dr., Tucson, AZ 85713 or copy and paste it into an email addressed to maryann@new-mindmachines.com US Residents $300 Insurance Information: The CES Ultra is not usually covered by most Medical insurance. Some insurance companies will, however, provide reimbursement for the device (E1399) with a medical order and certification of necessity. Supplies (A4556) will usually be covered without additional medical orders or certification. Some will only consider rental. I am NOT an insurance provider and will NOT file insurance for you.
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