Prior Authorization Request Form

Current Technology, Inc. will bill the third party payer if Prior Authorization has been obtained.

Complete this Prior Authorization Form and fax it to us. We will notify you about the outcome.

Note: Unfortunately, insurance companies do not guarantee payment and the patient needs to know they will be responsible for payment to Current Technology, Inc. if necessary.

If the third party payer does not cover the item, and the patient would like the device on a "self-pay" basis, we will bill them directly. (Credit card is required to process the order).

• Prior Authorization Request Form