Consent Form

Finnegan Health Services has been requested to provide one or more of the following products: bladder control, diabetic, urinary, ambulatory, ostomy, bath safety, wound, or nutritional supplies. Thank you for choosing us to provide your medical supplies. We are required by your insurance company to have a signed “CONSENT FORM” on file. This form gives us permission to bill your insurance for your supplies as you request them, and it provides proof that you received a copy of our current client bill of rights and privacy policy. This form also grants us permission to send text messages to the phone number on file in reference to matters of your account. If you have any questions please call our toll-free number: 1-888-789-6600. Thank you for your prompt attention. I understand that I may be held responsible for payment of non-covered services, including services received in excess of Medicaid benefit limitations.
Sincerely,
Finnegan Health Services

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.