Assignment of Benefits

Assigment of Benefits

First Name

Last Name

Birth Date

Phone Number

Please acknowledge that you have read and understand the following:

Consent 1

Verification of benefits is not a guarantee of payment. There is no way to determine if a claim will be applied to your deductible or co-insurance until after the claim is processed.

Consent 2

I hereby authorize Medicare/Medicaid and/or my other third-party insurance providers to pay my medical equipment, supplies and pharmacy benefit directly to Doyle Medical for products furnished to me by Doyle Medical. I further authorize any holder of protected health information (PHI) about me to release such information if required for Doyle Medical to file and process claims on my behalf. I authorize Doyle Medical to release to the Center for Medicare & Medicaid Services (CMS), third party payer and/or its agents any information needed to determine Medicare benefits or for audit purposes.

Consent 3

I have received a copy of Doyle Medical Privacy Practices as applicable to the Health Insurance Portability and Accountability Act (HIPAA) as well as a copy of CMS' Supplier Standards and a copy of the Patient Bill of Rights and Responsibilities. I understand how to use the products that have been dispensed to me or will receive training upon receipt, and warranty information is included with those products that carry a warranty.

Consent 4

I understand that I am responsible to pay Doyle Medical for any supplies or services not paid in full by my insurance. If my insurance should pay benefits or process claims directly to me for any merchandise provided by Doyle Medical, I will either endorse all checks as 'Pay to the order of Doyle Medical, LLC' or pay Doyle Medical by personal check or credit card. I will notify Doyle Medical of any changes in my insurance benefits, coverage, carrier or physician. I authorize Doyle Medical to contact me by telephone, auto call, mail, e-mail, text or other means in order to obtain authorization for shipments; or inform me of product recalls, releases and/or introductions; and/or to answer any billing, product or prescription questions.

HIPAA Release Authorization: I give my permission to Doyle Medical to disclose and release my protected health information described below to the following person or organization:

Relationship

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My Complete Health Record (Including but not limited to treatment and billing for all conditions). This health information may be used to enable the persons. I authorize to know and understand my condition and my treatment options for claims payment purposes, or related reasons.

All past, present and future periods pertaining to my DMEPOS Equipment and Supplies.

Please acknowledge the following

You may revoke this authorization in writing at anytime by notifying Doyle Medical. Please also note that information disclosed pursuant to the authorization may be redisclosed by the recipient and may no longer be protected.

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Thank you for doing business with Doyle Medical. In order for our family to properly take care of yours, please read the information before and acknowledge that you have read and accept the terms outlined in the following documents. Receiving your acceptance of the terms outlined in these forms allows our team to properly bill your insurance.

Please review and save the below documents for your reference:

Medicare Standards: English | Spanish

Doyle Medical Patient Bill of Rights and Responsibilities

Doyle Medical Complaints, Product Warranty, and Reorder Policies

Doyle Medical Return Policy

Doyle Medical HIPAA Privacy Notice

It is a requirement from your insurance that we have your handwritten or electronic signature on file, authorizing Doyle Medical to bill your insurance on your behalf. If you do not complete this form, we cannot bill your insurance and you will be responsible for payment for your recent order.

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Assignment of Benefits

Please acknowledge that you have read and understand the following:

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