I authorize the release of any medical or other information necessary for determining benefits payable for equipment or services and processing claims by the Center for Medicare & Medicaid Services, my insurance carrier and any other medical/insurance entity including insurance claim processors employed by Control Bionics. I understand that on occasion, funding or reimbursement barriers are encountered. I hereby authorize, if necessary, Control Bionics to release information related to my claim for funding to the Disability Law Center.

I authorize payment of insurance benefits, including Medicare if applicable, be made either to me or on my behalf to Control Bionics for any equipment or services provided to me. Should I receive payment directly from an insurance company, I agree to endorse and forward the check and “Explanation of Benefits” to Control Bionics within seven (7) days of receipt to:

Control Bionics
745 Center Street, Ste 303
Milford, OH 45150

I understand that failure to provide this information will result in myself being held legally responsible for payment in full for all equipment or services which I have been provided by Control Bionics.

I understand that I am financially responsible to Control Bionics for any charges not covered by health care benefits. I agree to notify Control Bionics of any changes made in my health care insurance coverage. In some cases, exact insurance benefits cannot be determined until the insurance company received the claim. I understand that I am responsible for the entire bill or balance of the bill as determined by Control Bionics and/or my health care insurer if the submitted claims, or any part of them, are denied for payment.

I understand that by signing this form, I am accepting financial responsibility as explained above for all payment for products received. This does not apply when Medicare determines the balance to be the contractor’s obligation.

I have read and understood Control Bionics’ Patient Bill of Rights and Responsibilities, the Control Bionics DMEPOS Supplier Standards, the Control Bionics Notice of Privacy Practices, and the Control Bionics 30 Day Return Policy.

Signature of Client/Legal Guardian/Power of Attorney: *
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