Derma Sciences Regions Map

Select your location from over 190 countries where Derma Sciences operates.

Reimbursement Forms

Derma Sciences Hotline Intake Form:
This form should be completed if you are interested to have the Derma Sciences Reimbursement Hotline for any of our products including AMNIOEXCEL® and AMNIOMATRIX®, TCC-EZ®, MedE-Kast® or MedE-Kast® Ultra
Download PDF Form

Business Associate Agreement for Derma Sciences Hotline:
This form should be completed if required by your health care compliance guidelines.
Download PDF Form

AMNIOEXCEL® and AMNIOMATRIX® Reimbursement Support Form:
This form should be completed if you are interested to have the Derma Sciences Reimbursement Hotline assist with determining benefits for AMNIOEXCEL® and AMNIOMATRIX®. Please ensure the patient has signed a consent form in your office. If they have not, please have them sign Amniotic Tissue Authorization to release PHI Form.
Download PDF Form

AMNIOEXCEL® and AMNIOMATRIX® Authorization to release PHI Form:
This form should be completed if you are interested to have the Derma Sciences Reimbursement Hotline assist with determining benefits for AMNIOEXCEL® and AMNIOMATRIX®. Please also complete AMNIOEXCEL® and AMNIOMATRIX® Reimbursement Support Form.
Download PDF Form

Template letters:
Template letters are provided as examples and for informational use only. They do not represent a guarantee, promise or statement by Derma Sciences, Inc. concerning levels of reimbursement, payment or charges. The decision as to procedure code selection, completion of a claim form and/or amount to bill, is exclusively the responsibility of the provider.
Download PDF Sample Amnioexcel preauth letter
Download PDF Sample Amnioexcel appeal letter
Download PDF Sample Appeal Letter TCC