Used Equipment Return Policy

The undersigned, as or on behalf of Patient, authorizes (1) Patient’s Insurer(s) and any other third party payor(s) which provide Patient with coverage to disclose to SUPPLIER minimum necessary  information to facilitate payment to SUPPLIER for items furnished Patient including, but not limited to (A) payment made by such payor(s) to Patient, the undersigned or to any other person  or entity for items provided by SUPPLIER to Patient; and (B) the scope and extent of Patient’s from time to time; (2) all medical personnel involved in Patient’s treatment to disclose to SUPPLIER any and all information concerning Patient’s medical history and condition as it may relate to the items or treatment provided to Patient by SUPPLIER; and (3) any holder of medical information about patient (including SUPPLIER) to release to the Centers for Medicare and Medicaid Services (or any successor agency) and its agents , to any of Patient’s third party payor(s) including, without limitation, Medicare, Medicaid, BCBS, OCHAMPUS, Tricare or other public or private payors, and to SUPPLIER, any information needed (subject to “minimum necessary” requirements as applicable) (A)  to determine applicable benefits and qualification for reimbursement of items furnished by SUPPLIER to Patient; (B) to process claims for items provided by SUPPLIER to Patient; and/or (C) to conduct health care compliance activities (including pre- or post-payment audits) and quality assurance or utilization reviews. The undersigned, as or on behalf of Patient, hereby authorizes his/her health care providers and payors to rely on this “Consent to Release of Health Information,” without the need for a separate release authorization , to release the specified information for treatment , payment and healthcare operations purposes as contemplated herein.  This consent shall not be effective to permit disclosures if information in cases where HIPAA-compliant release authorization is required pursuant to 45 CFR$164.508.