I authorize any holder of medical or other information about the below named client to release such information to Wound Management, the Centers for Medicare and Medicaid Services and it’s agents or any other payable insurance to whom application for payment has been made for services rendered to the below named client to any physicians, hospitals, other healthcare providers or facilities, institutions, or agencies providing treatment to the below named client. The Notice of Privacy Practices may be found at may also call to request the policy via mail. My signature below acknowledges that I have received a copy of the CMS (Medicare) Supplier Standards and a Notice of Privacy Practices. SUPPLIER STANDARDS & NOTICE OF PRIVACY PRACTICES The patient rights and responsibilities may be found at You may also call to request the policy via mail. My signature below acknowledges that I have received the statement of rights and responsibilities and it has been explained to me. Estimated patient responsibility can be obtained by contactimg our billing dept. I authorize Wound Management to bill my Insurance for the supplies provided and understand that I may be responsible for any deductibles or coinsurance. I understand that I have the right to make decisions concerning my medical care, including the right to accept or refuse medical or surgical treatment or medical supplies. I authorize WOUND MANAGEMENT to provide supplies and/or services as ordered by my physician. This assignment of benefits may be revoked at any time. I request that payment of authorized Medicare, Medicaid, and Private Insurance benefits be made payable to Wound Management for any services or products issued by Wound Management. If I choose to accept them while under a Home Health Episode, as defined by CMS, I may be financially responsible for the cost of these items. These supplies must be provided by my Home Health Service Provider.
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If my insurance is a Medicare plan, I understand that these supplies are not covered if I am receiving any kind of Home Health Services.