Assignments of Benefits / Release of Medical Records
Reliable Respiratory, Inc. (Reliable) is a CMS approved Home Medical Equipment (HME) provider. I hereby authorize Reliable to bill my insurance carrier or Medicare on my behalf for the costs of this service. I understand that I may be financially responsible for a deductible and/or co-payment and agree to make such payment if it is determined that my deductible or copayment has not been met at the time of billing. If I am deemed ineligible, by Medicare of other insurance carriers, to which Reliable submits an insurance claim(s) on my behalf, then I agree to pay the Usual and Customary charge of the service performed. I understand that certain equipment, supplies, and/or services may not be covered by my insurance company and may also be subject to a copay and/or a deductible. Any amounts not paid or covered by my insurance company will become my personal financial responsibility, for which Reliable Respiratory may charge my credit card on file.
I have been instructed on the use and care of the CPAP/BiPAP device by either a CPAP tech, the scheduling department or via online training resources, which can be found on Reliable’s site here.
I authorize any holder of my medical information to release any record pertaining to my medical history, services rendered, or treatment to Reliable Respiratory.
I authorize Reliable Respiratory to release my medical information to appropriate accreditation and insurance company personnel and other health care related organizations. I authorize the use of email to communicate with these organizations.
Acknowledgements:
If my insurance company pays me directly that I am responsible for forwarding those funds to Reliable.
I have been given a choice of HME providers and have chosen Reliable.
Reliable has not solicited me via any telemarketing or direct marketing means.