Did You Know...
that Medicare allows a foam prosthesis every six months or a silicone prosthesis every two years, and up to six bras every year?
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LONGVIEW
510 E. Loop 281
Longview, Texas
903-758-9904
800-525-2420
Fax: 903-236-9786

DALLAS
8499 Greenville Ave., Suite 99
Dallas, TX 75231
214-373-1045
Fax: 214-221-9282

  
 

Please complete this form if you have Medicare and/or Insurance and you would like us to file the claim for you.

Fill in every field and click"Submit"...the information will be sent via email to Women's Health Boutique - Longview, Texas.

Full Name
Street Address

City
State
Zip Code
Area Code & Telephone #
Email Address
Date Of Birth
Medicare #
Insurance Company
Insurance Company Address (Street, City, State)
Insurance Company Phone Number
Subscriber or Policy Number
Name of Primary Insured
Name of Doctor
Doctor's Address (Street, City, State)
Doctor's Phone Number
Diagnosis
If Mastectomy, Left, Right or Bilateral
Assignment of Benefits (NOTE - If you agree to assign benefits, you must print out and sign the Assigment of Benefits which will be mail to you with your purchase)

YES

NO


Release of medical information? (You must agree to have your pertinent medical information released to your insurance company and/or Medicare in order for WHB to file a claim)

YES

NO


 


 

 
 

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Meet our fitters!
We have been extensively trained to provide the most professional service in the healthcare industry.
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Lighter Prosthesis!
After 18 years of prosthesis fitting and listening to customer's needs, I designed a line of lighter prostheses exclusively for Women's Health Boutique.  You'll love how it gently fits against the body, draping into a natural position and shape.
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Watch our videos...
to learn how our products can help you regain your dignity, independence, and active lifestyle.
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