Leaving so soon?
Would you like to submit the form before you go?
AUTHORIZATION/CONSENT FOR CARE/SERVICE: I have been informed of the home care options available to me and of the selection of providers from which I may choose; and I have chosen MedSource, LLC, d/b/a insurancecoveredbackbraces.com, and its affiliates* (collectively referred to herein as “MedSource”) as my provider. I authorize MedSource to provide home medical equipment, supplies and services as prescribed by my physician and authorized by my insurance provider.
ASSIGNMENT OF BENEFITS/AUTHORIZATION FOR PAYMENT: I authorize MedSource to directly bill Medicare, Medicaid, Medicare Supplemental, or other insurer(s) on my behalf, for medical supplies furnished to me by MedSource; and I assign my rights and benefits from such insurers to MedSource.
PROVIDING INFORMATION: I am responsible for providing all necessary information and for making sure all certification and enrollment requirements for insurance coverage are fulfilled. I will report any change in my insurance coverage to MedSource within ten (10) days of such change. I confirm that I have not ordered another insurance covered back brace.
RELEASE OF INFORMATION: I authorize any holder of medical information about me to release to MedSource my physician(s), caregiver, CMS, its agents and to primary and/or other medical insurer any information needed to determine or secure eligibility information and/or reimbursement for covered services. I authorize MedSource to obtain medical or other information necessary in order to process my claim(s), including determining eligibility and seeking reimbursement for medical supplies provided.
FINANCIAL RESPONSIBILITY: I am responsible for the payment of all deductibles, co-payments, out-of-pocket requirements, and non-covered services. In the event my insurer denies coverage, I hereby agree to pay for such products/services provided by MedSource within thirty (30) days of receipt of an invoice. I agree that I am responsible for all late fees, interest and reasonably collection costs (including attorney’s fees) for any invoice not paid within thirty (30) days of receipt. I acknowledge my responsiblity for all the aforementioned charges, unless my agreement with my insurer holds me harmless from such charges.
RETURNED GOODS: Back braces may be returned in unopened packages with the seal intact within ninety (90) days from the date of service or purchase date. MedSource will not accept return of your back brace if the package is opened/seal is broken.
WARRANTY INFORMATION: Your back brace comes with a manufacturer’s warranty. The warranty lasts for 90 days. Please contact our custom support team directly if you have any questions or need additional information regarding the warranty.
CONSENT TO BEING CONTACTED BY MEDSOURCE: I consent to receive, live or automated, phone calls, e-mails, texts, and pre-recorded messages from MedSource regarding products and services, at the phone number(s) or email address I have provided.
AGREEMENT TO TERMS AND CONDITIONS: I am the patient or the patient's authorized representative and agree to the Terms and Conditions contained in this form and any other documentation provided by MedSource:
ABOUT FINANCIAL ARRANGEMENTS AND HEALTH INSURANCE: We are committed to providing you with the best possible care. If you have medical insurance, we are committed to helping you receive your maximum allowed benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policy. Payment for services is due at the time services are rendered unless payment arrangements have been approved in advance by our staff. We accept cash, checks, & most major credit cards. We will be happy to help you process your insurance claims for reimbursement of the services. Balances older than 90 days may be subject to additional collection fees and interest charges of 1.5 % per month. We must emphasize that, as healthcare providers, our relationship is with you, not your insurance company. While the filing of the insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that temporary financial problems may affect timely payment to your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about the above information or any uncertainty regarding your insurance coverage, don't hesitate to ask us. We are here to help you.
MEDICARE SUPPLIER STANDARDS: I have received and reviewed the Medicare Supplier Standards (for Medicare patients).
*Affiliates: Medequip, Alliance Medical, Integra, Merion Medical, Orthosquad, Fingerlakes Bracing, Arizona CPM and Medical Supply