
Complete the form below and our team will help verify your insurance benefits.
Before submitting the form, please have:
• Insurance card
• Physician information
• Diagnosis (if available)
Why This Form Is Required
To help determine if your insurance may cover a medical wig, we need your permission to securely review your information and communicate with your insurance provider if necessary.
Your information is protected under HIPAA privacy regulations and will only be used to assist with your insurance eligibility and consultation process.
After submitting your form:
Our cranial prosthesis specialists provide personalized, appointment-based consultations to help patients select medically appropriate hair solutions tailored to their needs. We also offer guidance on care, maintenance, and ongoing support throughout your journey.
Schedule your private consultation today.
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