Assignment of Benefits / Billing Authorization and Payment Form

I agree to the following when processing my medical supply order through my insurance with ADW Diabetes:

ADW Diabetes, LLC to directly submit claims on my behalf to Medicare, Medicaid, Medicare Supplemental, or other Insurer and/or their agents or assigns for products, equipment or medications furnished to me by ADW Diabetes LLC. Please be advised that Medicare does allow you the option to choose to either Rent or Purchase your meter. However, ADW Diabetes only offers meters as a purchase. ADW Diabetes, LLC to request, obtain and use my medical or other information as required to verify medical necessity, process my order(s) for products, equipment or medications, determine my insurance eligibility, coverage and benefits, submit claims for payment, and/or respond to Insurer or other legally authorized inquiries.

ADW Diabetes, LLC to release information in their files to their contracted agents, my physician, my caregiver, my Financially Responsible Party, my other medical professional, Medicare, Medicaid, Medicare Supplemental, or any other insurer(s), and/or their agents or assigns for purposes of managing my account. I acknowledge that I have received the Notice of Privacy Practices for ADW Diabetes. ADW Diabetes LLC will never sell, release or share your personal information to anyone other than as specified and only for purposes of managing your account.

ADW Diabetes, LLC and their agents to contact me by telephone and if needed leave a message on my voice mail, regular mail, email, text or facsimile for purposes of managing my account, to discuss my order(s) for medical items, equipment or medications, and to offer or explain other products and services that ADW Diabetes, LLC provides or may provide in the future. To promptly pay all amounts owed by me that are not covered by my Insurer(s) and for which I am responsible according to my Insurance/Benefit Plan’s participation criteria, such as co-insurance and deductible amounts and charges for non-covered items. In the event my insurer(s) should send an assigned payment directly to me instead of ADW Diabetes, LLC, I will endorse the check payable to ADW Diabetes, LLC and immediately forward it.

I will immediately notify ADW Diabetes, LLC prior to any change or cancellation of my health insurance coverage.