Assignment of Benefits (AOB) Form - Home Care Delivered 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Customer Name, Date of Birth, and Account number in the designated fields. Ensure accuracy as this information is crucial for processing your order.
3. In the Customer’s Phone # section, provide a valid phone number where you can be reached for any inquiries regarding your medical supplies.
4. Sign and date the form in the Customer’s Signature section. If you are unable to sign due to limitations, mark an 'x' and have a witness sign next to it.
5. If applicable, complete the Customer Representative Section by providing details about the Authorized Representative, including their signature and relationship to the patient.
6. Once all fields are filled out correctly, save your document. You can then fax it, scan and email it, or mail it using the provided envelope.

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