1. Assignment of Medicare, Medicaid, Medicare Supplemental or other insurance benefits to Alcam Medical, Inc. for medical supplies, devices, and/or equipment furnished to me by Alcam Medical, Inc.
2. Direct billing to Medicare, Medicaid, Medicare Supplemental or other insurer(s).
3. Release of my medical information to Medicare, Medicaid, Medicare Supplemental or other insurers and their agents and assigns.
4. Alcam Medical, Inc. to obtain medical or other information necessary in order to process my claim(s), including determining eligibility and seeking reimbursement for medical supplies, devices, and/or equipment provided.
5. Alcam Medical, Inc. to contact me by telephone or mail regarding my medical supplies, devices and/or equipment order(s).
6. I request that payment of Medicare, Medicaid, Medicare Supplemental or other insurance benefits be made on my behalf to Alcam Medical, Inc. for any medical supplies, devices and/or equipment furnished to me by Alcam Medical, Inc. I authorize any holder of medical information about me to release to Alcam Medical, Inc., my physician(s), caregiver, CMS, its agents and to my primary and/or other medical insurer any information needed to determine or secure eligibility information and/or reimbursement for covered services. I agree to pay all amounts that are not covered by my insurer(s) and for which I am responsible.
7. I understand that my eligibility for insurance coverage cannot be determined at this time. I wish to receive services from Alcam Medical, Inc. If it is determined that I am not eligible for coverage, I understand that I will be responsible for payment of all services provided.
8. I understand for Alcam to insure compensation, orders will be completed in a timely manner and upon completion, Alcam has the right to be able to process claims for work completed even despite cancellation and/or absence. If you cannot be located Alcam may attempt an unscheduled drive-by delivery to the last confirmed address of residence.