Patients Refill Request Form Refill Request Form Patient Name Patient Date Of Birth * Date Has your address changed? Yes No If so, please list new address Has your insurance changed? Yes No If so, please list new insurance Do you have supplies left? Yes No If so, please list items and quantities What supplies are you requesting? AUTHORIZATION and AGREEMENT FOR SERVICES HOME HEALTH CARE 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. These supplies must be provided by my Home Health Service Provider. 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. ASSIGNMENT OF BENEFITS 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. This assignment of benefits may be revoked at any time. AUTHORIZATION FOR SERVICES I authorize WOUND MANAGEMENT to provide supplies and/or services as ordered by my physician. 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 bill my Insurance for the supplies provided and understand that I may be responsible for any deductibles or coinsurance. Estimated patient responsibility can be obtained by contactimg our billing dept. RIGHTS AND RESPONSIBILITIES My signature below acknowledges that I have received the statement of rights and responsibilities and it has been explained to me. The patient rights and responsibilities may be found at www.woundmgmt.com. You may also call to request the policy via mail. SUPPLIER STANDARDS & NOTICE OF PRIVACY PRACTICES My signature below acknowledges that I have received a copy of the CMS (Medicare) Supplier Standards and a Notice of Privacy Practices. The Notice of Privacy Practices may be found at www.woundmgmt.com.You may also call to request the policy via mail. RELEASE OF INFORMATION 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. PRODUCT WARRANTY Please inspect your package upon delivery, and notify Wound Management if any supplies are missing or damaged. Wound Management will gladly pick up supplies that have been received in error, or are damaged in transit. Please contact our office within 48 hours of receiving your order to make arrangements for pick up. All other returns must be sent back to Wound Management within 14 days, and should be in new, unopened, and unaltered condition. All returns will undergo a quality control inspection, and credit will be issued on eligible items. Signature Clear If you are human, leave this field blank. . Submit Request a Refill FAQ's Upload Documents Request Tracking Info Satisfaction Survey E-Sign Patient Authorization Patient Notices Questions? Why not visit our contact page, we would love to chat with you!
