Follow Up Survey

We are honored that you have trusted our company with your medical supplies. To ensure continuation of supplies, your insurance company requires verification that these supplies are still reasonable and necessary for your daily care. Please take a moment to answer these required questions, sign the form and return in the included envelope. This gives us permission to continue shipping your order without delay.

Required Insurance Questionnaire for Continued Service

Basic Information

1. Has your address changed?

2. Has your insurance changed?

3. Has your doctor changed?

4. Thinking about the medical supplies you have on hand today; How many days will the supplies last before they run out?

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 to view this information.

Please use your finger or mouse to Sign

Please only click submit once, this process will take a moment to complete.