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Patient Agreement

First name

Last name

Phone

A few words about you

Your Signature

Select a date

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Phone

I acknowledge that I have received and been instructed in the proper use and care of the equipment and/or product listed above. I certify that the information given to Rehab Services in applying for equipment/product purchase/rental is correct. I authorize Rehab Services or its business partners to submit a claim to my insurer on my behalf and assign the benefits payable by my insurer to Rehab Services or its business partners. I understand I will be billed for any rental equipment while it is in my possession. I understand that billing will be stopped on the day that Rehab Services receives a call requesting a pickup of the equipment. In the event that my insurance carrier does not pay Rehab Services in full I will be responsible for all unpaid balances. If litigation is instituted to collect any unpaid balance, I agree to pay all costs of collection including reasonable attorney's fees incurred by Rehab Services. I authorize the release of medical records to any agent of Rehab Services for the purpose of providing documentation of medical necessity of the equipment I have received today. I acknowledge that I am responsible for the equipment while in my care, custody and control. I acknowledge that I have read, understand and agree to the terms and conditions as stated.