Home Rental Clinicians, our Home Rental program is simple and easy to get started. Simply fill out the form below to start the process for arranging a home rental unit for your patient. Pelvic Floor Stimulator Pathway STM-10 Utah Medical Liberty sEMG Biofeedback TR10 TR10c TR20 Does patient need a sensor? Pathway Vaginal Pathway Rectal UM-Vaginal UM-Rectal Other Other Does patient need other accessories? Billing? Self Pay Medicare Private Insurance Purchase or Rental? Purchase Rental Patient DetailsName First Last Date of Birth Format: 00/00/0000Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneMobile PhoneEmail Enter Email Confirm Email Emergency Contact (Name) Emergency Contact (Phone)Diagnosis & ICD-10 CodingICD-10 CodeN31.9 Detruser InstabilityN94.89 Pelvic Pain, FemaleM6240 Muscle Spasm, UspecN3941 Urge IncontinenceN393 Stress Incontinence, MaleN393 Stress Incontinence, FemaleN3946 Mixed IncontinenceR159 Fecal IncontinenceM6281 Muscle WeaknessICD-10 CodeN31.9 Detruser InstabilityM6240 Muscle Spasm, UspecN3941 Urge IncontinenceN393 Stress Incontinence, MaleN393 Stress Incontinence, FemaleN3946 Mixed IncontinenceR159 Fecal IncontinenceM6281 Muscle WeaknessICD-10 CodeN31.9 Detruser InstabilityN94.89 Pelvic Pain, FemaleM6240 Muscle Spasm, UspecN3941 Urge IncontinenceN393 Stress Incontinence, MaleN393 Stress Incontinence, FemaleN3946 Mixed IncontinenceR159 Fecal IncontinenceM6281 Muscle WeaknessOther Primary InsuranceInsurance Company Insurance PhonePrimary Insured Name First Last Insurance Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Group # ID # Secondary InsuranceInsurance Company Insurance PhoneSecondary Insured Name First Last Secondary Insurance Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Group # ID # Prescribing Physician InformationDoctor's Name NPI# Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Therapist InformationTherapist Facility Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Facility ID # DeliveryWhere will this be delivered? Please deliver to clinicians facility. Please deliver to patient's home** If ordering a STM-10 or TR-10C, would you like it programmed? Yes No STM-10:Session Time Duty Cycle Stim Mode TR-10C:Goal Above Below Work-Rest 5/10 Work-Rest 10/10 Scale 800UV 30UV Number Δ
