Referral Form

Text Authorization Form

This document allows MedSol to communicate by text message, email, and phone.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Name

First NameLast Name
Medical Solutions may contact me by text message, email, and or phone.
Phone#
Format: (000) 000-0000.
Email
example@example.com
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Comments from care provider (optional)
Use this section to inform us of sizes needed, color preference of rollator, or general comments.
Assignment of Benefits
Assignment I hereby request payment of my authorized carrier to be made on my behalf to Medical Solutions of Arkansas, LLC for current and reoccurring products and services they provide me. I further authorize a copy of this agreement to be used in place of the original and any holder of information about me is authorized to release such information to Medical Solutions of Arkansas, LLC and Health Care Finance Administration and any other insurance and/or their agents to assist in determining my benefits. Release of Information I hereby authorize the holder of medical or other information about me to release to the Social Security Administration, Centers for Medicare and Medicaid Services and its intermediary’s accreditation or regulatory agencies, or to any third-party payer, as required, any information needed for this or a related health claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the party who accepts assignment. I hereby authorize and medical facility, healthcare provider or other holder of medical information pertaining to me to release this information to Medical Solutions of AR, LLC or their representatives so that Medical Solutions of AR, LLC is able to prepare claims for submission on my behalf to Medicare, Medicaid or other third-party payers. Patient Responsibility I hereby guarantee payment to Medical Solutions of AR, LLC for any and all charges not covered by this assignment and waive any and all notices and demands in the event of non-payment there under. I am aware that Medical Solutions of AR, LLC will bill me for all deductible and co-pay charges on all equipment and/or supplies that I have rented and/or purchased each month. I also agree that all rental equipment will be returned to Medical Solutions of AR, LLC in good condition exclusive of normal wear through usage. I agree to compensate Medical Solutions of AR, LLC for any loss due to misuse, lost, stolen or damaged property. I hereby certify that I have read or have had this document read to me. I understand it’s content and intent, and with my signature so execute my permission, effective as dated. I acknowledge receiving a copy of the AHS Notice of Privacy Practices. The Assignment of Benefits authorizes your insurance company to pay us directly.
Change of Provider Request
My signature below serves as my notice to cancel equipment and or supplies with your company effective immediately. I will get all future services and supplies from: Medical Solutions of Arkansas 1000 E. Matthews Ave Suite F Jonesboro, AR 72401 1-870-910-0400This document will be used to notify your previous supplier that you are switching to Medical Solutions.
Confirm
Once you submit this form you will be directed to download our Patient Hub App.

1. The app will automatically open once you click submit below.

2. Wait 5-10 seconds

3. A popup will direct you to "Add Patient Hub" to your home screen.

4. Click the up arrow on the bottom of your phone screen

5. Then scroll to "Add to Home Screen"

You may use the Patient Hub App to look at our Product Booklet, Request your next months Re-Supply order, make a Patient Payment, etc.
Patient/Caregiver Signature - Using your finger please sign the request. This form may not be signed by staff of the following: home health agency, medical clinic, supply provider, or alike. Must be signed by the patient or direct inhome patient caregiver only.

Acknowledgement of requesting the equipment above, Assignment of Benefits, Release of Information, Patient Responsibility, and Change of Provider Request.
Should be Empty:

Text Authorization Form