We want to expedite your purchase as quickly as possible as we appreciate and value your time. We created a downloadable version of our forms that need to be completed and returned to us in order to process your item. Please choose the form below, print the form, and return it to us. Please see descriptions below to ensure you are completing the correct form.
- Assignment of Benefits / Release of Information
- HIPAA Signature Form
Returning the Form
Please return the form to us in order to complete the processing of your order. You can return this to us two different ways, through the mail, or via fax. Unfortunately, due to HIPAA regulations and to protect your privacy, we cannot accept forms sent to us through email.
952 546 2657
6024 Blue Circle Drive
Minnetonka, Minnesota 55343
Advanced Beneficiary Notice (ABN) Form
This is a notice given to beneficiaries in advance of their purchase that the product/service may not be covered. On this form Anodyne will indicate why we believe that our product will not be covered by insurance. The customer must select an option of whether to receive the supply knowing that they may be financially responsible.
Assignment of Benefits / Release of Information
The customer signs the Assignment of Benefits form indicating that their insurance should pay Anodyne Inc directly for the insurance companies responsibility of the product. This form authorizes the release of health information from your insurance company and doctors offices to Anodyne Inc.
HIPAA Signature Form