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  • Product(s) Requested:
     Breast Pump
     CPAP/Bilevel Equipment and Supplies
     Incontinence Supplies(Briefs, Diapers, Liners, Underpads. Etc.)
     Nebulizer Compressor and Supplies
  • Authorization and Acknowledgement

    Release of Information: I hereby consent to and authorize release of my medical records information to authorized representatives of insurance companies, Medicare, Medicaid, HMOs and other medical facilities for use in determining benefit coverage. I authorize the release of medical and other related information to my pharmacy, social/health care agencies, medical equipment/supply vendors whose services may be required in conjunction with the care/service provided by the organization and to any persons conducting internal audits for Total Home Health. Information may be distributed via facsimile, internet, interoffice mail, hand delivery, and/or mailed.

    Assignment of Benefits: Total Home Health will be filing on my behalf with Medicare, Medicaid, and/or private insurance. I request that all insurance benefits, otherwise assigned to me, be assigned to, and paid directly to Total Home Health for the products and services as listed above. Any co‐payment, deductible, or denied claims will be billed to me to be paid on demand after these agencies have received and taken action on claims for the items. I realize that some products and services provided by Total Home Health may not be covered by Medicare, Medicaid, or any other forms of insurance. Therefore, I will be held responsible for the full payment of such products and services deemed as "unassigned." These non‐covered products and services must be disclosed to me prior to my acceptance so that I may make payment arrangements or exercise my right to refuse the prescribed items. My physician will be notified should I refuse any product or service.

    Non‐ventilator or DME equipment: Unless the equipment is purchased by the patient (self‐pay), title and ownership remain with the provider (Total Home Health) unless the patient's insurance coverage provides for ownership after a certain number of months.

    Electronic Documentation: I agree to receive electronic documentation, emails, text messages and promotions from Total Home Health and affiliates.

    Telehealth Virtual Visit: I authorize the use of a Telehealth virtual visit for the use of instruction and/or troubleshoot of equipment.

  • Customer acknowledges receipt/delivery of the following:
     Supplier Standards
     Company's Notice of Privacy Practices
     Customer Rights and Responsibilities
  • Electronic Signature: Each party agrees that this Agreement and any other documents to be delivered in connection herewith may be electronically signed by typing your name in the box below, and that any electronic signatures appearing on this Agreement or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.