Brace Request Form & Authorization to Bill Insurance

Auth to Bill / Brace Request

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Patient Information

Facility Address(Required)
Max. file size: 100 MB.
Please upload patient facesheet so we can verify insurance and determine eligibility!
REHAB PAYER SOURCE(Required)
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Item Information

Side(Required)
What condition is the brace treating?

I am requesting this brace based on my recommendations and diagnosis listed above. I will fit and adjust the brace, if needed, on behalf of Pro Medical East or any of its affiliates.

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I request that payment of authorized Medicare/Medicaid or other private insurance benefits be made on my behalf for products/services furnished to me by Pro Medical East or any of its affiliates.

I authorize the release of medical information and records to the Center for Medicare and Medicaid Services (CMS), its Agents, third party payers or other parties necessary within the ordinary course of ensuring compliance with applicable quality of care, licensure or accreditation standards. I further authorize release of any information to other persons (only as authorized by law) needed to determine these benefits payable for related services.

I understand that I am financially responsible for any charges not covered by other payers (Medicare/Medicaid and/or other insurances), including but not limited to the following:

  • Annual deductible (if not met)
    • Medicare annual deductible for 2022 is $233.00.
  • Coinsurance
    • Medicare will cover 80% of the approved allowable charge. I am responsible for the 20% co-payment (if not covered by other payor sources).
  • Co-payments cannot be waived unless financial hardship is determined.
  • Rental/purchase price for equipment and/or supplies (if not covered by present insurance).
  • If I receive payment directly from an insurance company for products provided by Pro Medical East, it is my responsibility to forward payments and statements of paid services to them.

I may request a detailed statement of my account at any time by contacting the billing department at 732-657-9600.

I further verify that I have received information containing: Customer Bill of Rights and Responsibilities, Medicare Supplier Standards, General and emergency contact information, Customer Satisfaction Survey, HIPAA Privacy Notice, Capped Rental Information (Medicare Rentals), Company Grievance Process, Home and equipment safety information, equipment cleaning instructions (if applicable), prevention of infection, warranty information, the scope of services provided and possible associated fees. I understand my option to purchase or rent applicable DME items.

Signature

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