Texas Vein and Cosmetic Specialist
Durable Medical Equipment and Supplies
To Our Patients:
Many of the supply type items (compression stockings, support hose, and support socks) that are
dispensed in this office by the doctor are not covered by various insurance companies. We offer a
variety of various styles and brands of compression stockings, support hose, and support socks within
our office for the convenience of our patients. We are not a Durable Medical Equipment Supplier nor
do we have a DME number to submit claims to your insurance carrier. We will as a courtesy to you,
provide a receipt containing the necessary information for you, if you chose to submit your receipt to
your insurance carrier.
Please sign below to acknowledge and accept the policy for supply items dispensed in this office.
Signature of Patient/Responsible Person for Account
Print Name of Patient/Responsible Person for Account