Assignment of Benefits
I request that all payments from any insurance carrier, including Medicare, Medicaid or private insurance company be made on my behalf to Tidewater Medical Inc (TWM) for any equipment, supplies or services provided to me by TWM. I authorize the release of my medical information to HCFA and/or my insurance carrier and its agencies for the purpose of review of healthcare benefits for the determination of payment. This authorization will remain in effect until written notification by myself or my legal representative has been received. I agree to pay all amounts that are not covered by my insurer(s) including applicable co-payments and/or deductibles for which I am responsible. We will bill Medicare for 80%, and then bill your secondary insurance for any remaining 20%. You may be responsible for any remaining balances.
I have also received a copy of the following:
- Medicare Supplier Standards
- Rights and Responsibilities
- Complaint Procedures
- Notice of Privacy Practices
- Hours of Operation
- Warranty of Products