Medicare Patient Consent and AOB Form - revised 12-2014-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your personal information, including your name, phone number, Medicare number, and date of birth. Ensure accuracy as this information is crucial for processing your benefits.
3. In the section regarding insurance details, provide the name of any additional insurance and corresponding policy number if applicable. This helps in coordinating benefits effectively.
4. Review the consent statement carefully. By signing, you authorize Healthy Living Medical Supply to receive payment from Medicare or private insurance on your behalf.
5. Sign and date the form at the designated area. If a representative is signing for you, ensure they complete their details accurately in the provided section.
6. Once completed, save your document and follow the instructions to mail or fax it within 5 days to ensure timely processing.

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