Please complete the following pages to be eligible for Medicare/Medicaid billing.

Referral Source (if prepared by an agent or employee):

Patient Information
Name
Address
 
Phone Number      Email Address
Date of Birth          Social Security #
Gender          Height           Weight 

Emergency Contact Information
Name
Relationship     Phone Number

Physician Information
Physician     UPIN Number
Address     Phone Number

Billing Information
Insurance     HICN Number
Address     Phone Number
Policy Holder     Relationship
Secondary Ins.     HICN Number
Address     Phone Number
Policy Holder     Relationship

Equipment Ordered
  Rented Before?
  Rented Before?
  I agree that I was properly trained on how to safely use and operate this equipment.
  I agree that this equipment is in good working condition.
        I understand that if for any reason my medical insurance will not pay for my medical equipment and/or supplies whether it be purchased or rented basis provided by HARRISON MEDICAL/HEALTHPMO, I am wholly responsible for any deductible or out of pocket expense that is not covered by my medical insurance.

        HARRISON MEDICAL/HEALTHPMO assumes that the beneficiary will make every effort to keep equipment and/or supplies in good working order. While Harrison Medical/HEALTHPMO understands that normal wear will occur. Beneficiary agrees that if extensive repairs are required, additional charges may be levied.
Please Type Your Full Name Date