I acknowledge that I have chosen to use this particular device and Citizens Pharmacy. I authorize my healthcare provider and Citizens Pharmacy to release any of my medical information required by insurer to process the claim. I permit a copy of this authorization to be valid as the original. All costs of the device and/or supplies that are not paid for by my insurance company will become my responsibility. I shall be liable for all costs of collection. I hereby acknowledge that I have received a copy of the Patient Rights and Responsibilities and Privacy Notice on the reverse side of this form. I consent to receive Pharmacy Communications by Phone Call, Text Message and Email. I confirm the information provided by me in applying for payment under Medicare and/or any other insurance is true and correct. I request services/products/equipment furnished to me. I authorize any holder of health/medical or related information about me is released to Citizens Pharmacy agents for the purpose of determining benefits for related services/equipment/products, and applying for payment. I authorize Citizens Pharmacy to release to CMS, CMS Intermediaries, commercial insurance, accrediting bodies, state/federal entities as needed for insurance claims payments or quality assessment purposes. I have received all of the aforementioned documentation, and, I have been instructed in the safe and proper use of the aforementioned medical equipment and will use at home as taught.

(1) I have acknowledged that I have received the providers Notice of Privacy Practices which may be provided at my request. (2) For Medicare, Medicaid, or Insurance Billing: I authorize this provider to release information and request payment. I understand that the information given by me in applying for payment is correct. (3) I authorize the release of all records to act on this request and I request that the payment of benefits be made on my behalf.