HCPC: L0625 / L0650 / E0730 / A4556 / E0676 / E0603 Dx Code: Z34.90 ------------------------------------------------------------------------------------------------------------------------------ 

By signing below I acknowledge that I have read and received a copy of: DME Supplier Standard Patient Rights & Responsibilities. 

Patient Acknowledgment & Authorization to Assignment of Benefits (PA/AOB): I request that payment of authorized insurance be made on my behalf to NDM and its Assigns (listed below) for products & services that they provide to me. I further authorize a copy of this agreement to be used in place of the original to release to payers any information needed to determine these benefits or compliance with current healthcare standards. I understand that I am financially responsible for my health insurance deductible, coinsurance, co-payments or non-covered services. I acknowledge receiving instruction, have demonstrated or verbalized my understanding in the proper use and care of the equipment or supplies described and will follow them. I acknowledge receipt & understand the company patient information privacy notice and that all information on this document is correct.