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Assignment of Benefits (AOB)

This AOB is required to bill Medicare on your behalf. This form must be signed, completed and returned or submitted electronically before your order can be fulfilled.

My signature below authorizes each of the following:

1. Assignment of Medicare, Medicaid, Medicare supplement and/or other insurance benefits to
Grace Medical Inc for medical supplies furnished by Grace Medical Inc.

2. Direct billing to Medicare, Medicaid, Medicare supplement and/or other insurers.

3. Release of my medical information to Medicare, Medicaid, and other insurers and their

4. Grace Medical Inc. to obtain medical and other information necessary to process my claims,
including determining eligibility and seeking reimbursement for medical supplies provided.

5. Grace Medial Inc to contact me by telephone or mail regarding my medical supplies.

I request that payment of Medicare, Medicaid, Medicare supplement or other insurance benefits be made on my behalf to Grace Medical Inc.

I authorize any holder of medical information to release to Grace Medical Inc, my physician, CMS, caregiver, its agents and to my primary and other medical insurers.

I agree that I am responsible for all amounts not covered by Medicare and/or my insurer for which I am responsible including but not limited to any unmet portion of Medicare’s annual deductible.

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