National Biological: Contact Us about psoriasis, vitiligo, phototherapy units and equipment.

Complete PARTS A and B if you are requesting help with insurance reimbursement

Canadian customers
will be contacted by NOI, our EXCLUSIVE Canadian Distributor

PATIENTS PHYSICIANS THIRD PARTY PAYERS HOME

Would you like more information?
Use form below or call 800-338-5045.

Contact Information (PART A)

*Name

*Address

*City

*State/Province *Zip

*E-mail

Country

Telephone numbers - Best place to call:

Home

Cell Work x

Please tell us how we can help you:

	Primary reason for contact:
	Do you have a prescription (US patients)?
	How will you send prescription to us?
	Product you are interested in:
	Skin condition you are being treated for:
	How were you referred to us:
	Comments or Questions:
	Please click SUBMIT button only once.

Optional PART B. FREE help with Insurance Reimbursement:

Insurance Information (PART B)
We greatly value the privacy of our customers. All information provided to National Biological will remain strictly confidential and not be shared, sold or provided to any other company.
Patient Information
	Patient Name
	Relationship to Subscriber
	Patient Date of Birth	(MM/DD/YYYY)
Referring Physician
	Physician name
	Practice name
	Address
	City
	State		Zip:
	Phone
Insurance Carrier:
	Insurance Carrier
	Subscriber Name
	Subscriber/Member Number
	Group Number
	Member/Cust Service Phone
	Claim Address
	City
	State		Zip:
	Subscriber Date of Birth	(MM/DD/YYYY)

Please click submit button only once.

*** Required Fields

©2011 National Biological Corp.
23700 Mercantile Rd, Beachwood, OH 44122
Phone: (800 ) 338-5045 | Phone: (216) 831-0600 | Fax: (216) 765-0271            Updated: 10-20-11 NBC
info@PhototherapyExperts.com                                                                                  VDC 2.2   Millas designs