Healthcare Equipment Application

HEALTHCARE EQUIPMENT APPLICATION

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medicare/Medicaid Claim on Behalf: Medicare    Medicaid    Private Insurance    Self-pay

Equipment Requested

Request Type: New    Replacement    Repair    Rental    Purchase

Medical Necessity and Clinical Justification

Brief clinical justification for requested equipment (diagnosis, functional limitations, expected duration of need):

Current medications affecting mobility or respiratory function (if applicable):

Prescribing Provider Information

Required clinical attachments: I certify that copies of relevant progress notes, supporting documentation, and prior authorization forms are attached or will be provided upon request.

Delivery, Installation, and Billing Responsibility

Delivery address (if different from patient address):

Billing responsibility: Insurance    Patient / Guarantor    Third-party payer

Preferred delivery date (if needed):

HIPAA Authorization & Release of Information

I authorize the release of my medical and billing records necessary to process this equipment application and any related insurance claims. I understand that information disclosed may include diagnosis, treatment history, and functional assessments.

I acknowledge that I have received and read the provider's privacy practices and that this authorization is voluntary. I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. This authorization expires on:

Terms, Ownership, Maintenance and Liability

By submitting this application I agree to the following terms: I am responsible for notifying the supplier of any changes to my condition or insurance coverage. If equipment is rented, I accept responsibility for reasonable care and maintenance; I will return equipment in good condition upon termination of need. I understand that costs not covered by insurance are my responsibility.

Warranty and repair obligations: Supplier liability for equipment failure is limited to repair or replacement in accordance with the manufacturer's warranty and applicable law. I agree to report malfunctions promptly and to follow prescribed safety instructions.

Applicant Certification

I certify that the information on this application is true, complete, and accurate to the best of my knowledge. I authorize assignment of benefits to the equipment supplier and permit payment of medical benefits directly to the supplier when applicable. I understand falsification of information may result in denial of services and may be prosecuted under applicable law.

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