PLEASE READ CAREFULLY AND CHECK THE CHECK BOX AT THE END TO ACCEPT THIS FORM ELECTRONICALLY

Thank you for your interest in receiving your medical supplies (including incontinence, urological, ostomy, wound care, TENS units, enteral feeding and/or diabetics) through J&B Medical. We are honored to serve as your provider of choice for home medical equipment and supplies. Our billing department will conveniently submit all claims for you to ensure appropriate coverage of the products and services we provide. Please sign this Assignment of Benefits (AOB) form so that we may submit your claims to Medicare and/or your private health insurance provider.

1. I understand that signing this form authorizes J&B Medical to submit claims on my behalf directly to Medicaid, Medicare and/or my private health insurance provider. J&B Medical will accept assignment of these benefits. This means that J&B Medical will receive direct payment for the supplies and services provided. I agree to cooperate fully to secure such payment. I acknowledge that I am responsible for payment of copay, deductibles, and items not offered as a benefit.
2. I also understand that signing this form authorizes the release of medical or other information to the Centers for Medicare & Medicaid Services, my health insurance provider, J&B Medical Co., Inc., and the affiliates of J&B Medical.
3. I further understand that I must return this signed AOB form to J&B Medical in order for J&B Medical to continue to provide me with durable medical equipment products and services. If I choose not to sign and return this form, J&B Medical will not be able to continue to provide me with durable medical equipment products and services.
4. I have also received the Notice of Privacy Practices & Patients Rights & Responsibilities, CMS supplier standards, Complaint process, Warranty Information .