New Patient Paperwork Name* First Last Date of Birth*Phone #*Phone #Email *CANNOT SHIP TO PO BOXES, PLEASE MAKE SURE THIS IS A PHYSICAL ADDRESSAddress* Street Address City State / Province / Region ZIP / Postal Code * IF YOU ARE IN THE CARE OF A HOME HEALTH AGENCY PLEASE COMPLETE THIS SECTION Referring Agency Contact Person Phone # Fax # INSURANCE INFORMATIONPrimary Insurance Company* Member ID Group # Address Street Address City State / Province / Region ZIP / Postal Code Secondary Insurance Company Member ID Group # Address Street Address City State / Province / Region ZIP / Postal Code Medical InformationOrdering Physicans Name*SpecialtyPhone #FAX #Address Street Address City State / Province / Region ZIP / Postal Code RELEASE OF INFORMATION POLICY 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 of JCAHO benefits to Lifecare Technology, Inc. I understand I am responsible for any charges not paid by my insurance company(s). Furthermore, I authorized the above named authorized representative, to act in 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 9:00 A.M. – 4 P.M. Cash, check, Visa or Master Card is accepted for Non-Covered Items, and/or deductibles 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. CONSENT TO BILL: MEDICARE / MEDICAID / PRIVATE INSURANCE I request that a payment of Authorized (Medicare / Medicaid / Private) benefits be made on my (beneficiary) behalf to Lifecare Technology Medical Supply for any services furnished. Any holder of medical or other information about me (beneficiary) is authorized to release to the Center for Medicare & Medicaid services and /or Private Insurance, and its agents, any information needed to determine these benefits for release services. I understand that Lifecare Technology Medical Supply 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 of 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 Medical Supply. I have received and understand my Patient / Client of Bill of Rights, Medicare DMEPOS Supplies Standards, and Notices of Privacy. In addition, I agree that Lifecare Technology Medical Supply may contact me in the future via telephone or other means of communication regarding medical supplies. ASSIGNMENT / SIGNATURE ON FILE AGREEMENTI request that payment of authorized medical benefits be made to Lifecare Technology Medical Supply for any covered services furnished to me. In cases where Lifecare Technology Medical Supply will accept the charge determination as the full charge for the covered services, I am always responsible for the deductible, co-insurance, and unassigned uncovered services. I agree to pay Lifecare Technology Medical Supply any payment made directly to me by insurance for services provided by Lifecare Technology Medical Supply on an assigned basis. I understand that Lifecare Technology Medical Supply 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 Medical Supply if I relocate, no longer need supplies, or am admitted to a Hospital or Nursing Facility. Primary Insurance CardsSecondary Insurance CardsIDSignature*Date* Date Format: MM slash DD slash YYYY Representative's Name First Last Relation to Patient If you have any questions or concerns come up please let us know! We are available at 985-649-3019 to help however we can!