Assignment of Benefits

I request that payment of authorized insurance benefits, including Medicare, if I am a Medicare
beneficiary, be made on my behalf to the organization listed below for any equipment or services
provided to me by that organization.

I authorize the release of any medical or other information necessary to determine these benefits or the
benefits payable for related equipment or services to the organization, my insurance carrier or other
medical entity. A copy of this authorization will be sent to the my insurance company or other entity if
requested.

The original authorization will be kept on file by the organization. I understand that I am financially
responsible to the organization for any charges not covered by health care benefits. It is my
responsibility to notify the organization of any changes in my health care coverage. In some cases exact
insurance benefits cannot be determined until the insurance company receives the claim. I am
responsible for the entire bill or balance of the bill as determined by the organization and/or my health
care insurer if the submitted claims or any part of them are denied for payment. I understand that by
signing this form I am accepting financial responsibility as explained above for all payment for products
received.

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