PHONE: 330-297-9450 FAX: 330-297-9455

I request that payment of authorized insurance benefits, including Medicare if I am a Medicare beneficiary, be made on my behalf to M & J MEDICAL SUPPLY for any equipment or services M & J MEDICAL SUPPLY provided to me. I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related equipment or services to M &J MEDICAL SUPPLY, the Health Care Financing Administration, my insurance carrier, or other medical entity. If requested, a copy of this authorization will be sent to the Health Care Financing Administration, my insurance company, or another entity. The original authorization will be kept on file by

I understand that I am financially responsible to M & J MEDICAL SUPPLY for any charges not covered by health care benefits. I must notify M & J MEDICAL SUPPLY of any changes in my health care coverage. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by M & J MEDICAL SUPPLY and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payments for products received. Your portion of this bill will depend on your Insurance plan, deductibles, Co-Pay, and secondary insurance. By signing this document, I also acknowledge that I have received a copy of M & J MEDICAL SUPPLY'S Notice of Privacy Practices. This acknowledgment is required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made aware of my privacy rights. I have received a copy of 30 Medicare Supplier Standards Privacy Notice/HIPAA Patient's Rights & Responsibilities Warranty/Return Policy Complaint Process Service Availability

 

Financial Responsibility 

This letter serves as a formal agreement regarding the financial responsibility for services provided by M&J Medical Supply, LLC. By signing below, you acknowledge and agree to the following terms:

1. Responsibility for Payment You have agreed to receive services from the Company, and the Company has made arrangements to bill your health insurance provider for these services. However, regardless of whether the insurance provider approves or denies coverage, you, the Customer, remain financially responsible for the full amount of the charges in the event that your insurance does not pay the claim, denies the claim, or otherwise fails to cover the charges for any reason.

In the event that your health insurance provider does not pay or denies payment for any part or all of the charges for services rendered, you agree to immediately pay the outstanding balance directly to the Company.

This includes, but is not limited to, situations where:

The insurance company denies coverage based on policy exclusions, eligibility issues, or lack of medical necessity. The insurance company does not process the claim within the required time frame. The insurance company reduces the payment, and the remaining balance is deemed your responsibility. 3. No Guarantee of Insurance Payment You acknowledge that the Company does not guarantee that your insurance provider will cover all or any portion of the services provided. The Company will submit claims to your insurance, but if the insurance does not pay, the responsibility for payment will fall solely to you. 4. Payment Terms

If your insurance provider denies or fails to pay any portion of the charges, you agree to pay the balance in full within 65 days of notification from the Company. Payment can be made via phone, mail, online link etc., and any applicable late fees may be charged for overdue amounts.

You agree to indemnify and hold the Company harmless from any claims, damages, or losses arising out of or related to the denial of payment by your insurance provider, and from any failure to pay for services rendered in accordance with this agreement. 6. Acknowledgement By signing this letter, you acknowledge that you have read and understood the terms of this financial responsibility agreement and that you agree to be bound by the terms outlined above. By not signing this letter, you're services will be discontinued and you will need to find another provider for your services. If you have any questions or concerns, please do not hesitate to contact us at 330-297-9450 or

Sincerely, M&J Medical Supply, LLC

Customer Acknowledgement I, the undersigned, acknowledge and accept full responsibility for the payment of services provided by M & J Medical Supply, as outlined in this letter, in the event that my insurance provider denies or fails to pay the claim.