|
Customer Name: _________________________________________________ |
| Address:
___________________________________________ |
Assignment of BenefitsThank you for
your interest in becoming a valued member of our customer family. We look
forward to serving you. One of our complimentary services is to submit
insurance and billing claims for you, easing the paperwork burden and
lessening your out-of-pocket costs. In order for us to bill Medicare and
your private health insurance provider, please sign this Assignment of
Benefits (AOB) form.
| I understand
that signing this form authorizes: |
| 1. |
Advanced Diabetes Supply
to submit claims on my behalf directly to Medicare and my private
health insurance provider. Advanced Diabetes Supply will accept
assignment of these benefits, which means Advanced Diabetes Supply
will receive direct payment for the supplies and services provided.
|
|
| 2. |
The release of medical
or other information to the Centers for Medicare & Medicaid
Services, my health insurance provider, Advanced Diabetes Supply
affiliates, and Advanced Diabetes Supply.
|
|
| Also,
I understand that: |
| 3. |
I must return this signed AOB form
to Advanced Diabetes Supply in order for Advanced Diabetes Supply
to continue to provide me with products and services. If I choose
not to sign and return this form, Advanced Diabetes Supply will not
be able to continue to provide me with products and service |
| Please
Sign Here |
____________________________ |
Date: |
______________ |
|
|
If someone other
than the beneficiary is signing this form, please complete the following
information for the person signing this form:
|
| Relationship
to beneficiary: ____________________________________________________________ |
| Address
____________________________________________________________ |
| |
Street
Address |
City |
State |
Zip |
|
| Phone:
( ____ - _______ - ________ ) |
|
Reason why beneficiary cannot sign this form:
|
| ____________________________________________________________
|
