By signing this form I agree to the following:
1. I authorize direct payment of insurance benefits by my insurance company to Total Medical Supply, Inc.
2. In the event that my insurance carrier does not accept “assignment of benefits”, I understand that payment may be sent to me directly and that I am obligated to endorse and send such payment to Total Medical Supply, Inc. for payment of my bill.
3. I understand that I am responsible to Total Medical Supply, Inc. for all charges not covered by my insurance.
4. I recognize that in the event that my insurance company, employer, or any third party payer refuses to pay for the item(s) provided to me by Total Medical Supply, Inc. or delays the payment beyond 90 days of my receipt of item(s), or in the event that I have no coverage or third party, that I will be responsible for said payments and will make reimbursement within 30 days of notification by Total Medical Supply, Inc. for all charges.
5. I have received Medicare Supplier Standards and Notice of Privacy Practice.