Supplier Change Consent Form

Patient Information

This is the date you would like us to start your service.

This is the last date you received a shipment from the previous provider.


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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Patient Representative

If the patient is unable to sign, a representative may sign above on their behalf.

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