Proof of Delivery & Assignment of Benefits Form

Proof of Delivery & Assignment of Benefits Form

Please complete this form to confirm receipt of equipment and authorize benefits transfer.
SMG MEDIQUIP, LLC

P.O. BOX 736, BETHPAGE, NY 11714

PHONE: 516-586-4934 / FAX: 800-717-2573
Patient Name*
E0730 TENS Unit (Includes supplies: A4557 and either A4556 or A4595) - Provides pain relief by transmitting electrical impulses through lead wires and surface electrodes to underlying nervesL0648 Aspen Horizon 631 LSO - Designed to provide trunk stability to fatigued muscles. Provides a therapeutic level of compression for patients recovering from surgery or injury. Anterior panels at each end of the brace overlap to provide added midline supportE0849 Theratrac Cervical Traction Unit - Offers up to 30 lbs of adjustable pneumatic pressureL0648 Theratrac Lumbar brace with Pneumatic Traction - Utilizes pneumatic bladder technology to administer a moderate lumbar decompression stretch, to gently contour the innate spinal path and unload the weight on the lower lumbarL0457 Aspen Horizon 456 TLSO - Designed to provide motion restriction, creating a dynamic environment for healing within the thoracolumbar and lumbar spineL0457 Aspen Active P-TLSO - This device is designed to actively influence posture by providing gentle support while activating and strengthening the necessary muscles that promote proper spinal alignmentL1833 Comfortland Hinged Knee Brace - An adjustable ROM hinge helps to stabilize the knee and promote proper alignmentE0731 Conductive Garment for TENS (Garmetrode)Other
E0730 TENS Unit - A4557 Quantity
E0730 TENS Unit -A4556 Quantity
E0730 TENS Unit -A4595 Quantity
E0730 TENS Unit - Billed over how many months ?
ASSIGNMENT OF BENEFITS
I hereby assign all medical and surgical benefits, to include major medical benefits, to which I am entitled. I hereby authorize and direct my insurance carrier to issue payment check(s) directly to SMG Mediquip, LLC, for medical services rendered to myself and/or my dependents, regardless of my insurance benefits, if any.

I hereby authorize SMG Mediquip, LLC to (1) release any information necessary to insurance carriers regarding my treatments and condition; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing
ACKNOWLEDGMENT OF PROOF OF DELIVERY AND ASSIGNMENT OF BENEFITS:
Patient Signature*

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Date of Receipt of Equipment*

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Date
Patient Address
Primary Phone
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Patient Email
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