Consent & Acknowledgement

Privacy Practices: I acknowledge receipt of Norco’s Orientation Handbook and Notice of Privacy Practices, available at Norco Branches or www.norco-inc.com. I understand my rights and Norco’s responsibilities regarding my health information.

I authorize Norco to bill Medicare/insurers on my behalf and release necessary medical information to them and to care providers.  I understand I am responsible for any unpaid charges.

TCPA Text & Email Communications: I expressly consent to receive automated text messages, calls and emails from Norco and its service providers regarding my order status, shipping updates, delivery notifications, resupply requests, account receivable balances and any related transactional information.  I understand that message and data rates may apply, and consent is not required as a condition of purchase.  I acknowledge that I may receive recurring messages and can opt out at any time by replying STOP to text messages or following the unsubscribe instruction in emails.  I certify that I am the owner or authorized user of the mobile number and email address provided.  I agree that any disputes related to these communications will be resolved through individual arbitration only.  I waive any right to participate in class action lawsuits or class arbitration regarding these communications.

Customer Release of Information/Authorization to Assign Benefits I hereby request payment of my authorized Medicare or other carrier benefits to be made on my behalf to NORCO MEDICAL (Norco) for any products and services that they furnish me. I further authorize that a copy of this agreement can be used in place of the original and authorize Norco or any holder of medical information about me to release to Medicare (CMS), any other insurer and/or their agents any information needed to determine these benefits. I authorize the release of medical information about me to Norco. I also authorize Norco to release medical information about me to nursing agencies or physicians involved in my care, and any other regulatory or accrediting body governing Norco’s scope of service. Norco bills third party payors as a courtesy; I understand that I am fully responsible for all deductibles, coinsurances, disallowables and that a prescription from my physician does not guarantee my insurance carrier’s participation for payment.

Customer Agreements I hereby agree to the terms below regarding the rental/purchase of equipment and/or supplies from Norco:

• Norco bills monthly and does not prorate rentals.
• I understand that I am financially responsible to Norco for all charges incurred through the term of this agreement.
• I hereby acknowledge receiving full instructions and have demonstrated my understanding in the proper use and care of the equipment and/or supplies that have been delivered to me and are described on Norco's shipper or picking ticket.
• I understand that I will be held responsible for any piece of my durable medical equipment and/or supplies that have been damaged, defaced, lost, or destroyed as a result of neglect, abuse, or misuse of the item.
• I agree to make arrangements within two weeks of entering either a hospital or a skilled nursing facility or when the medical necessity for the equipment no longer exists to return all equipment to Norco.

I have read the above sections and understand the Customer Agreements noted on this form. I acknowledge that the Norco Patient Orientation Handbook has been provided online for my review at www.norcomedical.com/patient-referral. I also understand that in the event my insurance carrier denies payment for any reason, I am responsible for payment to Norco for the items delivered.