34406 North 27th Drive
Bldg 8 Unit 182
Phoenix AZ 85085
Phone: 877-893-5305
Lifetime Assignment of Benefits/Release

I authorize the release of any medical or other information necessary for determining benefits payable for equipment or services and processing claims by the Centers for Medicare & Medicaid Services, my insurance carrier and any other medical/insurance entity. I understand that on occasion, funding or reimbursement barriers are encountered.

I authorize payment of my insurance benefits be made either to me or on my behalf to Northland/Lincare for any equipment or services provided to me. In certain circumstances, my insurance company may send a check for services provided by Northland directly to me. If that happens, I agree to contact Northland at 1-877-893-5305 within 5 business days of receipt of check from my insurer to arrange payment to Northland.

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