Insurance Forms

  Signature Forms Package

This is a single file with all of the forms listed below:

• FAX cover sheet
• Release of Information
• Rental Terms & Conditions
• Advanced Beneficiary Notice
• Written Confirmation of Receipt of Required Medicare Notices
• Medicare Supplier Standards
• Equipment Warranty
• Notice of Privacy Practices Pursuant to HIPAA
• Capped Rental Agreement
• Patients Rights & Responsibilities

  FAX Cover Sheet

Use this cover sheet to return the required signature forms to your OWL Leasing, Inc. Personal Care Consultant.

  Release of Information

Release of personal medical information according to standards of HIPAA.

  Rental Terms & Conditions

Explains the terms and conditions of the rental agreement.

  Advanced Beneficiary Notice

Explains that Medicare does not reimburse the rental expense for the face down rental equipment.

  Written Confirmation of Receipt of Required Medicare Notices

Evidences receipt by Medicare patient of documents required to be provided by Medicare.

  Medicare Supplier Standards

26 DMEPOS supplier standards required by Medicare.

  Equipment Warranty

Face down recovery rental equipment.

  Notice of Privacy Practices Pursuant to HIPAA

This notice describes how patient health information may be used.

  Medicare Capped Rental Agreement

For services on or after January 1, 2006.

  Patients Rights & Responsibilities

Important information to reference during rental period.

  Assignment of Benefits

DMEPOS medical supplier request for payment form.