STATEMENT TO PERMIT PAYMENT OF INSURANCE BENEFITS TO PROVIDER, PHYSICIAN, AND PATIENT


I request that payment of authorized Medicare and/or private insurance benefits be made either to me or on my behalf to MHM Group, LLC. d/b/a Baby Pavilion for any services furnished to me by Baby Pavilion. I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services and/or my private insurance, and its agents, any information needed to determine these benefits for related services.

I understand that Baby Pavilion reserves the right to review all agreements on an individual basis to determine the continued acceptance of assignment for Medicare and/or any other medical insurance companies. In the event medical necessity no longer exists or my payer no longer deems my supplies to be covered, I understand I must return the unopened, reusable supplies to Baby Pavilion so they may refund my insurance. I agree to call before returning the supplies.

I acknowledge receipt and understanding of my Patient/Client Bill of Rights, Medicare DMEPOS Supplier Standards, and Notice of Privacy Practices that I received as part of my supply order and understand that I may also view a copy of these documents at www.babypavilon.com. I also acknowledge that I have received and/or will receive training on the use of all products I order from Baby Pavilion. In addition, I agree that Baby Pavilion may contact me in the future, via telephone, email, instant messaging, mail or other means of communication, regarding ordering medical supplies.

Note: If the patient is physically or mentally unable to sign, a representative may sign on the patient’s behalf. In addition, the representative’s signature, date signed, representative's name (print), address, relationship to the patient and reason why the patient cannot sign must be listed below.