WHOLESALWHOLESALE DIVISION

SAMPLE KNEE BRACING HCFA 1500 FORM

18011 MITCHELL SOUTH • IRVINE, CA • 92614 | PHONE 800.652.1135 FAX 800.652.1126 | WWW.VQORTHOCARE.COM

Sample Unilateral Knee Bracing HCFA 1500 FORM

***Billing information, including charges listed, are intended as a sample only and VQ OrthoCare does not guarantee reimbursement from any insurance company. All billing practices are the responsibility of each individual provider.***

SAMPLE

WHOLESALWHOLESALE DIVISION

SAMPLE KNEE BRACING HCFA 1500 FORM

18011 MITCHELL SOUTH • IRVINE, CA • 92614 | PHONE 800.652.1135 FAX 800.652.1126 | WWW.VQORTHOCARE.COM

© 2015 VisionQuest Industries, Inc. WH151820REVB

Sample Bilateral Knee Bracing HCFA 1500 FORM

***Billing information, including charges listed, are intended as a sample only and VQ OrthoCare does not guarantee reimbursement from any insurance company. All billing practices are the responsibility of each individual provider.***

SAMPLE