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

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PART B to request help with insurance reimbursement

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

PATIENTS PHYSICIANS THIRD PARTY PAYERS HOME

Would you like a brochure? More Information?
Use form below or call 800-338-5045. We are here to help.

Contact Information (PART A)

*First.Name

*Last.Name

*Address

*City

*State/Province *Zip

*E-mail

Country

Telephone numbers - Best place to call:

Home

Work Cell

Please tell us how we can help you:

	Product you are interested in:
	Skin condition you are being treated for:
	How were you referred to National Biological:
	Comments or Questions:

Want FREE help with Insurance Reimbursement? Continue below (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:
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:

* Required Fields

©2010 National Biological Corp.
23700 Mercantile Rd, Beachwood, OH 44122
Phone: (800) 338-5045 | Phone: (216) 831-0600 | Fax: (216) 765-0271            Updated: 8-25-10 NBC
info@PhototherapyExperts.com                                                                                  VDC 2.2   Millas designs