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.
1. Medical Information Authorization
I authorize any holder of medical information relating to me to release to Reliable Respiratory any record pertaining to my medical history, services rendered, or treatment. I authorize Reliable Respiratory to release my medical information to appropriate accreditation and insurance company personnel and other health care related organizations. I authorize use of email to communicate with these organizations.
2. Financial Responsibility
I understand that insurance coverage is not guaranteed and remain responsible for all amounts not paid by insurance, including denied claims, copayments, deductibles, coinsurance, and other non-covered charges. 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 or 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. I authorize Reliable Respiratory to charge the credit card on file for such amounts. Any balance that remains unpaid more than fourteen (14) days after the due date may be subject to collection efforts, and Reliable Respiratory may require the return of equipment until the account is paid in full.
3. Communications and Call Recording Consent
I also authorize Reliable Respiratory and its service providers to contact me by non-automated, automated, or AI-assisted calls, text messages, emails, and other digital communication channels regarding care, therapy, resupply, information related to my medical supplies, scheduling, billing, payment, and provider coordination. Calls may be recorded. Consent to receive such communications is not a condition of receiving care or services. Message and data rates may apply. I may opt out of marketing or non-essential communications at any time by replying STOP, using an unsubscribe option, or contacting Reliable Respiratory.
4. Assignment of Insurance Benefits
I authorize any and all Medicare, Medicaid, or other insurance benefits to be paid directly to Reliable Respiratory for any equipment or services furnished to me by Reliable Respiratory.
Acknowledgements:
- If my insurance company pays me directly, 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.
Acknowledgement specific to CPAP/BIPAP Users:
I have been instructed on the use and care of the PAP Device equipment by either a Customer Service Representative, the scheduling department, or via online training resources, which can be found on Reliable’s site here.