A F O a n d S H O E S m a r k e t i n g P o r t f o l i o

M a r k e t i n g P o r t f o l i o

O U R P R O G R A M O V E R V I E W

S P E C I A L T Y H O M E M E D I C A L S O L U T I O N SPOWERED BY CROWNQUEST, INC.

CONTACT US:Phone: 517-316-0802Fax: 616-988-6552 www.neurogenxathome.com

C U S T O M E RSATISFACTION

RATING

100%C U S T O M E R RECOMMENDATION

R A T E

100%

DURABLE MEDICAL EQUIPMENT

Exemplary ProviderWe assist physicians and therapists with INSURANCE BILLING

We assist patients with obtaining MAXIMUM insurance coverage

We can quickly order/obtain SPECIAL ORDER products from any manufacturer as soon as 24hrs

We ship nationwide within 24 hours so you have what you need, as soon as you need it

We have been in business SINCE 2004, located in Lansing, Michigan

We work with most INSURANCES including Medicare, Medicaid

We have HIGHEST CUSTOMER SATISFACTION rating in the industry

QUALITY PRODUCTS INCLUDE:

• Heat & Cold Applications• Neuromuscular Electrical Stimulators (NMES)

• Cervical Traction Equipment

• Transcutaneous Electrical Nerve Stimulators (TENS)

• Custom-Fabricated Orthotics

• Prefabricated Orthotics• Off-The-Shelf Orthotics• Neurostimulators

• Diabetic Shoes / Off-The-Shelf Inserts• Diabetic Shoes / Custom Inserts

• Surgical Dressings

• Breast Pumps• Burn and Compression Garments

Many other products . . . just let us know what you need!

TOLL-FREE: 800-335-7624

• Braces – Wrist, Knee, Ankle, Lower Back

M a r k e t i n g P o r t f o l i o

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The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of the person(s) named above. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message.

NGX-ATHOME-FAX-82718

TOLL-FREE: 800-335-7624

O P E R AT I O N A L F O R M S

FORM COMPLETION INSTRUCTIONSPage 1 of 1

(c) 2018 Neurogenx/CrownQuest. All rights reserved.

NGX-AT-HOME-COMPLETE.DEL.INST-V1-020618

314 N. Walnut Street • Suite 2A • Lansing, MI 48933 • OFFICE: 517-316-0802 • TOLL-FREE: 1-800-335-7624 • FAX: 616-988-6552 • www.neurogenxathome.com

The forms listed below must be returned to us before we can bill the patient’s insurance. Please return these completed forms to us the day that the patient is given the equipment. If we do not receive the forms, we cannot legally bill the insurance and will be forced to bill the patient directly. You may fax the forms to (616) 988-6552. Thank you for your help! Neurogenx At Home by CrownquestPLEASE HAVE THE PATIENT COMPLETE THE FOLLOWING:• DME Delivery Instruction Form

1. Date of visit: (Located top right corner) 2. Patient Attestation Section (located at the bottom of the page) Please include: - Patient Printed Name - Patient Signature & Date - Employee signature & Date – trained patient on equipment

• Notice of Privacy Practices 1. Patient Name 2. Patient Date of Birth 3. Signature & Date

• Medicare Capped Rental (If Included) 1. Patient Signature & Date

• Assignment of Benefits 1. Patient Signature & Date 2. Patient Medicare Number 3. Additional Insurance Information if available

HOW TO COMPLETE THE DME DELIVERY INSTRUCTION FORM

Additional Info:

Page 1 of 1

(c) 2018 Neurogenx/CrownQuest. All rights reserved.

NGX-AT-HOME-PAT.RR-SPANISH-V1-020618

314 N. Walnut Street • Suite 2A • Lansing, MI 48933 • OFFICE: 517-316-0802 • TOLL-FREE: 1-800-335-7624 • FAX: 616-988-6552 • www.neurogenxathome.com

Derechos del paciente y responsabilidades

Derechos del paciente:

Responsabilidades del pacientes:1.elpacientedebenotificarinmediatamenteaNeurogenxAtHomebyCrownquestde

cualquierfallaodaño.2.elpacienteesresponsableporcualquierequipoquepierdeolerobanmientrasestéensu

posesiónydebenotificarinmediatamenteaNeurogenxAtHomebyCrownquest.

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cualquiercambiorelativoasumédico.5.elpacientedebenotificaraNeurogenxAtHomebyCrownquestdelainterrupción

desuuso.

6.exceptodondecontrariosalasleyesfederalesoestatales,elpacienteesresponsable

porcualquiercargodealquileryventadeequiposquecompañía/compañíasdesegurosdel

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lainformaciónrelativaalserviciodesuequipomédico.Individuosuorganizaciones

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consentimientoporescritodepacientes.4.elpacientetieneelderechodetomarunadecisióninformadaacercadesucuidado.

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6.elpacientetieneelderechoalaquejadevozsintemordelaterminacióndelservicioode

otrasrepresaliasenelprocesodeservicio.

C U S T O M E RSATISFACTION

RATING

100%C U S T O M E R RECOMMENDATION

R A T E

100%

A C C R E D I TAT I O N S

S u p p l e m e n t s

5000SPECIAL FORMULA

2000SPECIAL FORMULA SPECIAL FORMULA

POSITIVE RESULTS

• Decrease numbness and pain in feet, hands and legs• Lower blood pressure back to healthy levels• Increase circulation and sensation in the extremities• Increase energy and endurance• Start experiencing these results in a few days

Proprietary blend

Neurogenx® Nerve Health Solution is based on the Nobel Prize winning findings of Dr. Louis Ignarro. Neurogenx Neuropathy Relief Solution has the most beneficial blend of L-Arginine and L-Citrulline to enhance the effects of Nitric Oxide. The body’s own natural ability to produce Nitric Oxide is reduced as we age. The ingredients in Neurogenx® Nerve Health Solution were chosen for their ability to support the

body’s production of Nitric Oxide and be an important part of your daily healthy nutritional plan.*

*These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure or prevent disease.

4 flavors to choose from

AVAILABLE ONLY THROUGH your Healthcare Professional

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