Authorization of Benefits Form Patient ID Patient Name: Patient Address City, State Zip: Phone: Patient Estimated total charges: Primary insurance coverage amount: 2nd and/or 3rd insurance coverage: Patient estimate responsibility: Trust Home Medical Reviewed by digital signature: *I request payment of authorized Medicare and/or insurance benefits to me or on my behalf for any services furnished by Trust Home Medical, LLC. I authorize any holder of medical information about me to release to Medicare, its agents, Insurance and Trust Home Medical any information needed to determine/bill these benefits. I authorize Trust Home Medical, LLC. to contact me for any reason. I or my caregiver can properly use the supplies requested. Patient responsible for payments not paid by Medicare and/or Insurance including deductibles and co-insurance. Please ship and bill Medicare and/or my insurance for my complete order I am requesting.HiddenSignatureHiddenEnter your email address here to receive a copy of your Authorization of Benefits