I acknowledge that I have chosen to use this particular device and Gwinnett Drugs. I authorize my healthcare provider and Gwinnett Drugs 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 Gwinnett Drugs agents for the purpose of determining benefits for related services/equipment/products and applying for payment. I authorize Gwinnett Drugs 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.