Assignment of Benefits / HIPPA Disclosure and Related Documents Print this page NOTE: PDF files (requires Adobe Reader) - right click & select "Save Target As..."
By signing this form, I authorize the release of any medical or other information necessary to bill my insurance provider on my behalf. I also authorize payment with medical / government benefits to Spectrum Diabetic Services for equipment or supplies provided to me. I agree to pay all amounts that are not covered by my insurer(s) including applicable co-payments and/or deductibles for which I am
responsible.
I also acknowledge the receipt of the following:
*Patient Rights & Responsibilities
*Consent to Privacy Practices
*Notification of Information Practices
*Notice of Privacy Practices
*21 Medicare Supplier Standards
*Spectrum Diabetic Services, LLC Pertinent Information Sheet & Return Policy
