Supplier Change Consent Form
I authorize Finnegan Health Services to provide medical supplies to me as ordered by my physician, case manager, or myself. I am aware that Medicare or Medicaid will only pay one provider for services rendered, and that I may be responsible for
payment to Finnegan Health Services if payment is denied due to another provider billing for the same service within the same time period. I have notified all of my other suppliers and informed them that I will no longer require their services
after the “service start date” given above.
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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
If the patient is unable to sign, a representative may sign above on their behalf.