QTF Interior Banner 3 Mobile - Medical Release/Assignment of Benefits

Client Information Form

Medical Release/Assignment of Benefits

  • I authorize the release of any medical or other information necessary for determining benefits payable for equipment and processing claims by my insurance carrier, accrediting agencies, and any other medical/ insurance entity. If requested, a copy of this authorization will be sent to my insurance company or other medical insurance entity.

    I authorize payment of insurance benefits to AbleNet, Inc. for any equipment provided to me. If I fail to provide all insurance information, including Medicare and Medicaid, I also understand that I could be held legally responsible for payment in full for all equipment provided. I also understand that I am financially responsible for any charges not covered by my healthcare benefits. NOTE: You will be notified, in advance, if there are any applicable charges.

    By signing this document, I am authorizing the medical release of information as well as acknowledging that I have downloaded and understand AbleNet's warranty and return policy, patient rights and responsibilities, supplier standards, client privacy information, product manual, and complaint policy.

    NOTE: A copy of this medical release document will be sent to the email address you provide below as well as copies of AbleNet’s return policy, patient rights and responsibilities, the supplier standards, and client privacy information.
  • The individual for whom the device is being requested.
  • The individual for whom the device is being requested.
  • Electronic Signature Acknowledgement * Required
  • **Parent /Legal Guardian signature required if child is a minor

  • Date Format: MM slash DD slash YYYY
  • A copy of this form and the AbleNet return policy, patient rights and responsibilities, the supplier standards, and the client privacy information will be sent to this email address.

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