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Web by providing this form to an authorized afflovest distributor, i acknowledge that the patient is aware that he or she may be contacted by said distributor for any. Leaving blank presumes lifetime (99 months) 3. Use this simple medicare checklist to determine whether your patients meet the guidelines for medicare, medicaid and private insurance. Web order form download corporate office: 3701 wayzata blvd, suite 300 minneapolis, mn 55416 phone: Market availability, and is approved for medicare, medicaid, and private health insurance reimbursement under the. (measure fullest part of chest at nipple line) 4. Web the aflovest has received the fda’s 510k clearance for u.s.