Obtain Criterion Products

Criterion products are prescription medical devices that must be purchased through a physician
or other licensed medical provider.

In order to obtain a Criterion device, your physician must fill out and submit the following forms
to Criterion:

- RSA1V2A

RSA1V2A (2 page document) includes all necessary information to obtain a Criterion device:
Letter of Medical Necessity, Assignment of Benefits, Release of Information and Product
Request Forms.

If you need a prescribing physician, fill out the form below and Criterion will locate one for you.

Please fill out the following form for all other product information requests or call our Customer
Care Department (800)-573-0093:
Fields with an * are required.

**Product Request:
*First Name:
*Last Name:
Patient ID #:
Company:
*Address:
*City:
*State:
*ZIP:
*Email:
*Phone:
*Contact Preference:	Phone Email

Comments:

Ordering Supplies Direct are for Cash Patients Only. Insurance Coverage may limit Supply Order Requests.



	Pain Management
	Rehabilitation
	Reduce Swelling
	Obtain Criterion Products

- Electrodes

- Order Supplies Direct