Patient Intake & Insurance Pre-Qualification
Start Your Medical Wig Insurance Verification
If you are experiencing hair loss due to a medical condition, your insurance plan may provide coverage or reimbursement for a cranial prosthesis (medical wig).
At Purdy Medical Wigs & DME Supplier, we help guide patients through the process of understanding their insurance benefits and selecting the right cranial prosthesis.
To begin, please complete our secure Patient Intake & Insurance Pre-Qualification Form.
Your information is protected and handled in accordance with HIPAA privacy regulations.
Start the Process
Why We Ask You to Complete This Form
To determine whether your insurance may cover a cranial prosthesis, we may need permission to review your insurance information and communicate with your insurance provider or healthcare provider if necessary.
Completing this form allows Purdy Medical Wigs & DME Supplier to assist you with:
• Insurance benefit verification
• Documentation requirements
• Consultation preparation
• Cranial prosthesis recommendations
Your information is used only for the purpose of assisting you with your insurance eligibility and consultation process.
What You May Need Before Completing the Form
To help us review your eligibility faster, please have the following information available:
• Your insurance card
• Basic personal information
• Physician or healthcare provider information (if available)
• Diagnosis related to hair loss (if known)
Providing accurate information helps us guide you through the process more efficiently.
Conditions That May Qualify for Coverage
Insurance plans may provide coverage when hair loss is related to certain medical conditions such as:
• Chemotherapy or cancer treatment
• Alopecia
• Lupus
• Thyroid disorders
• Trichotillomania
• Other medically diagnosed hair loss conditions
Coverage varies depending on the individual insurance policy.
Complete Your Secure Intake Form
To begin the insurance eligibility process, please complete our secure HIPAA-compliant intake form below.
This form allows our team to review your information and determine the next steps in the process.
Begin the Secure Form
- 🔒 HIPAA Compliant
- 🧾 Insurance Accepted
- 🤝 Compassionate Care
What Happens After You Submit the Form
Once your form is submitted, our team will review your information and begin the eligibility review
The next steps may include:
1️⃣ Reviewing your insurance information
2️⃣ Determining documentation requirements
3️⃣ Scheduling a consultation appointment
4️⃣ Discussing cranial prosthesis options
Our goal is to guide you through the process with care and professionalism.
Ready to Continue?
After submitting the intake form, you can schedule a consultation to explore your medical wig options and receive personalized guidance.