I authorize the release of any medical information necessary to process any insurance claims for any items provided to me by Lifecare Technology, Inc. I authorize payment of any private insurance company, government or JCAHO benefits to Lifecare Technology, Inc.

I understand I am responsible for any charges not paid by my insurance company(s). Furthermore, I authorize the above-named authorized representative to act on my behalf as my representative in all matters of business with Lifecare Technology, Inc.

Your supplies will be supplied to you from Lifecare Technology, Inc. For questions, service, or to order additional supplies, please call 985.649.3019. Our office hours are Monday–Friday, 9:00am–4:00pm.

Cash, check, Visa, or MasterCard is accepted for non-covered items, deductible and co-payments. I understand that I am responsible for payment if I fail to update Lifecare Technology, Inc. of any changes in healthcare, insurance, or living arrangements.

I request that a payment of authorized Medicare, Medicaid, or Private Insurance benefits be made on my behalf to Lifecare Technology, Inc. for any services furnished.

Any holder of medical or other information about me is authorized to release to the Centers for Medicare and Medicaid Services and/or Private Insurance, and its agents, any information needed to determine these benefits for released services.

I understand that Lifecare Technology, Inc. reserves the right to review all agreements on an individual basis to determine the continued acceptance of assignment for Medicare and/or any other medical insurance companies.

In the event medical necessity no longer exists or my payer no longer deems any supplies to be covered, I understand that I will be responsible for all payments to Lifecare Technology, Inc.

I have received and understand my Patient/Client Bill of Rights, Medicare DMEPOS Supplies Standards, and Notice of Privacy.

I agree that Lifecare Technology, Inc. may contact me in the future via telephone or other means of communication regarding medical supplies.

I request that payment of authorized medical benefits be made to Lifecare Technology, Inc. for any covered services furnished to me.

I understand that I am responsible for the deductible, co-insurance, and unassigned uncovered services.

I agree to pay Lifecare Technology, Inc. any payment made directly to me by insurance for services provided by Lifecare Technology, Inc. on an assigned basis.

I understand that Lifecare Technology, Inc. does not accept returned merchandise if worn, used for sanitary/hygienic purposes, or if it is disposable.

It is my responsibility to inform Lifecare Technology, Inc. if I relocate, no longer need supplies, or am admitted to a hospital or nursing facility.