Assignment of Benefits (AOB) – This AOB form is required to bill on your behalf!

1. Assignment of Medicare, Medicaid, Medicare Supplemental or other insurance benefits to HEALTHCARE DME, LLC for medical supplies and/or

medication(s) furnished to me by HEALTHCARE DME, LLC

2. Direct billing to Medicare, Medicaid, Medicare Supplemental or other insurer(s).
3. Release of my medical information to Medicare, Medicaid, Medicare Supplemental or other insurers and their agents and assigns.

4.HEALTHCARE DME, LLC to obtain medical or other information necessary in order to process my claim(s), including determining eligibility and seeking

reimbursement for medical supplies and/or medication(s) provided.

5. HEALTHCARE DME, LLC to contact me by telephone or mail regarding my medical supplies and/or medication(s) order.

I agree to pay all amounts that are not covered by my insurer(s) including applicable co-payments and/or deductibles for which I am responsible.

I request that payment of Medicare, Medicaid, Medicare Supplemental or other insurance benefits be made on my behalf to HEALTHCARE DME, LLC for any

medical supplies and/or medications furnished to me by HEALTHCARE DME, LLC I authorize any holder of medical information about me to release to

HEALTHCARE DME, LLC my physician(s), caregiver, CMS, its agents and to my primary and/or other medical insurer any information needed to determine

or secure eligibility information and/or reimbursement for covered services. I agree to pay all amounts that are not covered by my insurer(s) and for which I am

Responsible.

Equipment Warranty Information

1. Every product sold or rented by our company carries a 1-year manufacturer’s warranty unless otherwise specified.
2. HEALTHCARE DME, LLC will notify all insurance beneficiaries of the warranty coverage, and we will honor all warranties under applicable law.

3.HEALTHCARE DME, LLC will repair or replace, free of charge, insurance-covered equipment that is under warranty. In addition, an owner’s manual with

warranty information will be provided to beneficiaries for all durable medical equipment where this manual is available.

4. I have been instructed in and I understand the warranty coverage on the product that I have received.