Supplier Change Consent Form

I request that payment of authorized Medicare, Medicaid, and/or private insurance benefits be made either to me or on my behalf to Finnegan’s Inc. dba Finnegan Health Services for any services furnished to me by Finnegan Health Services. I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services and/or my private insurance, and its agents, any information needed to determine these bene ts for related services. I understand that Finnegan Health Services reserves the right to review all agreements on an individual basis to determine the continued acceptance of assignment for Medicare, Medicaid, and/or any other medical insurance companies. In the event medical necessity no longer exists or my payer no longer deems my supplies to be covered, I understand I must return the unopened, reusable supplies to Finnegan Health Services so they may refund my insurance. I understand I must notify Finnegan Health Services immediately if any information changes such as my address, physician, or insurance eligibility. I may be held responsible for payment if services are denied because I did not report these changes. I have received and understand my Patient/Client Bill of Rights, Medicare DMEPOS Supplier Standards, Notice of Privacy Practices, complaint procedures, and a listing of services provided by Finnegan Health Services. I understand I may have to meet certain requirements for coverage and I may have a deductible and/or co-pay according to my insurance plan. These estimated amounts will be provided before services are rendered. In addition, I agree that Finnegan Health Services may contact me in the future via telephone or other means of communication regarding ordering medical supplies. Medical supplies will be delivered within 3-4 business days after we have received the requested information and the physician’s orders. I have received instruction and understand how to use my equipment and I understand that some equipment may have a limited warranty. I understand that I can call Finnegan Health Services at any time to receive additional instruction and warranty information on equipment.