Please include city, state, and zip as well.
Consent for Continuing Services: I request payment of authorized Medicare, Medicaid and/or other health
insurance benefits to me or on my behalf for any services furnished me by Finnegan Health Services. I authorize any
holder of medical information about me to release to Medicare, Medicaid and/or other health insurance and its
agents any information needed to determine these benefits or benefits for related services. I have received a packet
containing HIPPA practices, supplier standards, bill of rights, complaint resolution, warranty and product
instructions. I understand I can visit www.finnegahealth.com to view this information.