Purdy Medical Wigs & DME Suppliers Patient Intake and Order Request Form

I understand that photographs, head measurements, fitting information, and other documentation may be collected by Purdy Medical Wigs & DME Supplier LLC or an authorized Purdy fitting partner/vendor when reasonably necessary to evaluate fit, coordinate or construct my cranial prosthesis/medical wig, document authorized services, or support applicable insurance or reimbursement processes.

IMPORTANT: Patient fitting or medical-wig photographs will not be authorized for social media, advertising, testimonials, before-and-after promotions, or other marketing merely because the patient completed this intake form. Marketing/promotional use must be handled through a separate appropriate photo/media authorization.

Purdy Medical Wigs & DME Supplier LLC may coordinate certain authorized cranial prosthesis and medical wig services with independent fitting partners, salons, wig specialists, vendors, healthcare professionals, and other service providers involved in the patient's care or authorized services. I authorize Purdy Medical Wigs & DME Supplier LLC, when appropriate and permitted by applicable law, to disclose information reasonably necessary to coordinate and provide my authorized cranial prosthesis/medical wig services to an authorized Purdy fitting partner, vendor, or other service provider involved in my case. Information disclosed may include, as applicable: • My name and contact information • Appointment and scheduling information • Cranial prosthesis/medical wig order information • Hair-loss related information relevant to the authorized service • Prescription and medical-necessity information when reasonably necessary • Head measurements and fitting information • Photographs taken for fitting, measurement, construction, customization, documentation, or insurance purposes • Hair color, texture, length, density, cap, lace, style, and other product specifications • Insurance-related information reasonably necessary to coordinate the authorized service • Other information reasonably necessary to complete my authorized cranial prosthesis or medical wig services The fitting partner/vendor may use the information provided by Purdy only for the purpose of performing or coordinating the authorized services, subject to applicable privacy requirements and the partner/vendor's agreement with Purdy. This authorization does NOT authorize a fitting partner, vendor, salon, or other third party to use my photographs, medical information, or other personal information for advertising, social media, promotional content, testimonials, or marketing. Any such use requires a separate written authorization when required.

Insurance coverage, reimbursement, network rules, claim decisions, and payment amounts are determined by the patient’s insurance carrier. Purdy Medical Wigs & DME Suppliers LLC cannot guarantee approval, coverage, reimbursement, or payment.

I authorize Purdy Medical Wigs & DME Suppliers LLC to communicate with my insurance company regarding benefits, coverage, prior authorization or exception requirements, claims/reimbursement procedures, and related documentation as permitted by applicable law.

I authorize Purdy Medical Wigs & DME Supplier LLC to communicate with my healthcare providers, as permitted by applicable law, to obtain or coordinate prescriptions, letters of medical necessity, diagnoses, or supporting information reasonably necessary for my cranial prosthesis services.

I authorize the use and disclosure of protected health information reasonably necessary to coordinate my authorized cranial prosthesis services, subject to applicable privacy law and Purdy Medical Wigs & DME Supplier LLC’s privacy practices. This does not by itself authorize marketing use of my protected health information or photographs.

I acknowledge that I have received or had access to Purdy Medical Wigs & DME Supplier LLC’s Notice of Privacy Practices.

Please select the communication methods Purdy Medical Wigs & DME Supplier LLC may use for scheduling and patient-service coordination.

I understand that I am financially responsible for amounts due for authorized products and services that are not paid directly by my insurance carrier. When Purdy Medical Wigs & DME Supplier LLC is not participating/in-network with my plan or when the payer requires member reimbursement, I may be required to pay Purdy before ordering, production, fitting completion, or delivery.

Purdy may assist with insurance documentation and reimbursement procedures; however, reimbursement is not guaranteed.

Custom or specially ordered cranial prostheses may have limited cancellation, return, remake, or refund rights after materials are ordered or production begins, subject to applicable order terms and law.

Purdy Medical Wigs & DME Supplier LLC does not diagnose or treat medical conditions. Purdy provides cranial prosthesis products, consultation, insurance guidance, documentation support, fitting coordination, and related patient-care services within its authorized scope.

I certify that the information I provided in this form is accurate to the best of my knowledge. I acknowledge that I have read and understand the applicable sections of this form and have had an opportunity to ask questions.