Please review the following statements: Patient Release/ AOB/ Complaint Policy/ Delivery Proof/ Privacy Notice/ Terms and Conditions Agreement.
The Company is the supplier. I understand that the equipment is to be used only for my diagnosed condition and will be issued under a doctor's prescription. I am aware product(s) instructions, use of equipment(s), and product(s) warnings/precautions are available on “The Company” website, www.go-telehealth.com/recources/ I also understand the company and/or my health care provider will review product(s) instructions, use of equipment(s), and product(s) warnings/precautions with me before use. I absolve the company, responsibility in the event of any accident or injury from the use of this equipment.
I authorize "The Company" to provide supplies for this equipment as prescribed by my doctor. Should my supplies become over or under stock, I understand that it is my responsibility to contact "The Company."
I understand the following items: Rights & Responsibilities, Service availability of company, Privacy notice, medicare supply standards, cleaning and maintenance of equipment, equipment instructions, complaint process, warranty information, return policy are available on “The Company” website, www.directens.com/resources/. I have read and/or been instructed in detail on the above items. I understand the above items and should I have any additional questions I should contact "The Company."
I hereby acknowledge and affirm that I will confirm received delivery of the device prescribed/ordered for my home use and that I have been fitted with the device and instructed upon its use and I understand the instruction(s) I have received.
I hereby authorize and request that payment of my medical insurer or other insurance benefits, including auto/worker’s compensation insurance carrier, attorney lien, to be made on my behalf to “The Company” for any medical product(s), equipment/supplies, DME services furnished to me by “The Company”. I request payment directly to "The Company" such sums that maybe due for any medical product(s), equipment/supplies, DME services rendered. In the event that my insurance company has a preferred provider that is considered in network, I instruct my insurance company to apply my out of network benefits. I hereby further give a lien on my worker’s compensation or auto injury claim to "The Company", against any and all proceeds of any settlement, judgement, or verdict that may be paid to me or to my attorney.
I authorize any holder of medical information about me to release to "The Company", my physician(s), caregiver, CMS, its agents and to my primary and/or medical insurer, or other insurer, any information needed to determine or secure eligibility information and/or reimbursement for covered services.