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When you place an order with Anodyne, we may ask that you provide information via one or more of the below forms. Please see a description of each form below. Click to download documents as needed.
IMPORTANT: Once you have filled out your information, you may return forms to us either by postal mail or via fax. Due to HIPAA regulations protecting your privacy, we can not accept the forms electronically or via email.
Mail
Anodyne Inc.
6024 Blue Circle Drive
Minnetonka, Minnesota, 55343
Fax
(952) 546-2657
This form allows you to request services from Anodyne. Please provide as much information as you have so we can complete the order as soon as possible. Providing your contact information allows us to reach out if necessary. We may also check with the nurse or physician for additional documentation and guidance. If a physician’s prescription is available, you may include that as well. Instructions for returning the form are included above.
The Assignment of Benefits form indicates that you have insurance and that your insurance company should pay Anodyne Inc. directly for the products that we provide to you. This form also authorizes the release of health information from your insurance company and doctors offices to Anodyne Inc. Please review the form in its' entirety, fill out and return as required. Instructions for returning the form are included above.
This form allows you to grant verbal-only access to others regarding your medical and financial information. It also indicates that you were provided with a copy of our HIPAA Privacy Policy as well as given the opportunity to review our supplier standards and a obtain a copy of them at your request. Please review the form in its' entirety, fill out and return as required. Instructions for returning the form are included above.
This form is to be completed and signed by a physician. For clients ordering supplies or equiment from Anodyne, a signed doctor's prescription is often required. The form provides Anodyne a detailed written order authorization and certification of medical need for supplies or equipment. Instructions for returning the form are included above.
This form is to be completed and signed by a physician. For clients ordering a Cervical Traction Device, the form provides Anodyne a detailed written order authorization and certification of medical need for the unit. Instructions for returning the form are included above.
Anodyne, Inc.'s HIPAA Privacy Policy form describes how medical information about you may be used and disclosed and how you can get access to this information. We understand the confidential nature of the information you provide to Anodyne Inc. We want you to understand how Anodyne may use and disclose certain information you provide us, and what rights you have concerning that information. Please review the form in its' entirety for details.
