
HAIR LOSS INSURANCE COVERAGE
We kindly ask our customers to complete the consent form below for the cranial prosthesis.
This form is necessary for us to obtain your consent to contact and speak on your behalf to verify insurance details and to file the claim for your prosthesis.
Currently, the insurances that will pay upfront for our Peruca wigs are Cigna, Aetna, and Blue Cross Blue Shield. Your cooperation ensures a smooth and efficient process, allowing us to provide you with the highest quality service and support.
Thank you for choosing Real Perucas!
AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION
Please fill in the information and upload your Member ID Card.
One of our peruca assistants will follow up with you within 24hrs to confirm your consent form and guide you through the application process.​
​HIPAA Release of information
AUTHORIZATION FORM


