Assignment Of Benefits for Medicare Billing
I assign the right and responsibility to Maggy Pharmacy Inc to bill on my behalf, and accept payment for Medicare DMEPOS products, and services provided to me, the Beneficiary.
I understand that I am responsible to pay any deductible amount applied to the claims and coinsurance, which is 20 percent of the allowable or approved charge for a product or service.
I permit Maggy Pharmacy Inc to release and collect my health information, and other information, as required (and as permitted by the HIPAA Regulations) from my health care provider and Medicare to receive payment from Medicare.
I understand that this form will be maintained and made available to Medicare or its representatives.