Order Forms For Prescriber Use

The following PDF order forms are available for prescribing Altivera devices and supplies. Please select the appropriate form based on the patient's insurance and the product being ordered, and ensure all required fields are completed to avoid processing delays.

• DME Order Form (PDF)

  For Commercial, Medicare, Medicaid, TRICARE, VA, and Self-Pay patients. Use this form to order all covered Altivera DME products.

• E-Stim Order Form (PDF)

  For Commercial, Medicare, Medicaid, TRICARE, VA, and Self-Pay patients. Use this form when ordering electrotherapy (e-stim) devices only.

• Liability Order Form (PDF)

  For Workers' Compensation, Auto, and Personal Injury claims. Use this form for all Altivera products billed under liability coverage.