Family Home Medical Equipment & Supply, LLC
                 2605 Tamiami Trail, Suite 10, Port Charlotte, FL 33952
                     941-624-0127     941-485-5250     941-429-2996


                              Consent for Services
                     Authorization for Release of Information


Patient Name: ______________________________________________

Consent for Services
I hereby consent to receive care / services from Family Home Medical Equipment & Supply.

Financial Responsibility
I understand that I am financially responsible for all charges  relating to equipment, 
supplies & services provided by Family Home Medical, that are not reimbursed by insurance 
benefits.  I understand my obligation to pay for the charges according to the specified
 payment terms.  I understand it is my responsibility to notify Family Home Medical of any 
changes in my insurance coverages.

Assignment of Insurance Benefits and Release of Information
I hereby authorize my insurance company / fund to pay benefits on my behalf for this service 
directly to Family Home Medical.

To the extent necessary to determine liability for payment and obtain reinbursement, I 
authorize the release of my medical records, to any person, organization or agency which 
is or may be liable for all or any portion of the charge, including but not limited to 
insurance companies, health care service plans, worker’s compensation carriers and government
 agencies.

I hereby authorize any holders of relevant health care information (physicians, hospitals,
 home health agencies, etc.) to release such information to Family Home Medical.  I also 
authorize Family Home Medical to release my records and/or healthcare information, related
 to the care / relevant services which Family Home Medical is providing to me, to other
 healthcare providers and organizations including federal, state and local agencies.



Signature: ____________________________________   Date: ___________________


I also allow the following people to discuss with you any matter pertaining to my case.

___________________________________  Relation:____________________________


___________________________________  Relation:____________________________