Patient New Product Request Form

Patient New Product Request Form

This form is to be used by the patient to request new equipment and other supplies. Medical Solutions will do the rest of the paperwork on your behalf.
If you are a physician or referral facility please use the forms created specifically for your facility type. There is a physician order form as well as a referral facility form. This patient inquiry form is only for patient use. Thank you in advance.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient First Name (Legal)
Patient Last Name
Email
example@example.com
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Person Completing this request
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Height
Patient Weight
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Name & Phone #
Primary Insurance Name & Policy Number
Do you have Arkansas Medicaid or PASSE program?
Arkansas Medicaid ID# or PASSE ID# - if applicable
Insurance Card Image (optional)

Upload pictures of the patients current insurance card(s) Primary - Secondary - Tertiary
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
Reason for equipment request (diagnosis or ailment)
**In order to qualify for incontinent supplies the patient will need a diagnosis of urinary incontinence, nocturnal enuresis, or mixed incontinence. Other qualifying conditions exist such as autism, developmental delay, cerebral palsy, ADHD, PTSD, Hirschsprung's disease, spina bifida, etc.
Equipment Requested:
Full Range Medicaid ONLY covered equipment:
Additional information we may need to know(optional)
Use this section to inform us of sizes needed, color preference of rollator, or general comments.
Confirm
Assignment of Benefits
Assignment I hereby request payment of my authorized carrier to be made on my behalf to Medical Solutions of Arkansas, LLC for current and reoccurring products and services they provide me. I further authorize a copy of this agreement to be used in place of the original and any holder of information about me is authorized to release such information to Medical Solutions of Arkansas, LLC and Health Care Finance Administration and any other insurance and/or their agents to assist in determining my benefits. Release of Information I hereby authorize the holder of medical or other information about me to release to the Social Security Administration, Centers for Medicare and Medicaid Services and its intermediary’s accreditation or regulatory agencies, or to any third-party payer, as required, any information needed for this or a related health claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the party who accepts assignment. I hereby authorize and medical facility, healthcare provider or other holder of medical information pertaining to me to release this information to Medical Solutions of AR, LLC or their representatives so that Medical Solutions of AR, LLC is able to prepare claims for submission on my behalf to Medicare, Medicaid or other third-party payers. Patient Responsibility I hereby guarantee payment to Medical Solutions of AR, LLC for any and all charges not covered by this assignment and waive any and all notices and demands in the event of non-payment there under. I am aware that Medical Solutions of AR, LLC will bill me for all deductible and co-pay charges on all equipment and/or supplies that I have rented and/or purchased each month. I also agree that all rental equipment will be returned to Medical Solutions of AR, LLC in good condition exclusive of normal wear through usage. I agree to compensate Medical Solutions of AR, LLC for any loss due to misuse, lost, stolen or damaged property. I hereby certify that I have read or have had this document read to me. I understand it’s content and intent, and with my signature so execute my permission, effective as dated. I acknowledge receiving a copy of the AHS Notice of Privacy Practices. The Assignment of Benefits authorizes your insurance company to pay us directly.
Change of Provider Request
My signature below serves as my notice to cancel equipment and or supplies with your company effective immediately. I will get all future services and supplies from: Medical Solutions of Arkansas 1000 E. Matthews Ave Suite F Jonesboro, AR 72401 1-870-910-0400This document will be used to notify your previous supplier that you are switching to Medical Solutions.
Patient/Caregiver Signature - Using your finger please sign the request. This form may not be signed by staff of the following: home health agency, medical clinic, supply provider, or alike. Must be signed by the patient or direct in home patient caregiver only.

Acknowledgement of requesting the equipment above, Assignment of Benefits, Release of Information, Patient Responsibility, and Change of Provider Request.
Should be Empty:

Patient New Product Request Form

Insurance Card Image (optional)