Authorization of Benefits Form

  • Review for accuracy, if anything is wrong you must contact your Trust Home Medical rep. Once done reviewing, sign below in the box with your mouse and enter your email address to receive a copy for your records.

  • * 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. I understand only samples may be free and will arrive with a complete order as prescribed by my physician to be billed to my insurance.