Nebulizador PARI Copa Formulario de Pedido

PARI Nebulizer Cup Order Form

  • Your Information

  • Insurance Information

  • Please Read and Sign

    • I understand that Neb Doctors of Maryland, LLC or its assignee (“Provider”) is independently owned and operated and is not in any way associated with a hospital, medical practice or any other clinic.
    • I certify that the information provided by me and applying for payment under title XVIII (Medicare) of the Social Security Act of any other insurance benefits is true and correct.
    • I understand that if my insurance coverage is denied, I am responsible to pay Provider the usual and customary amount/ price for this equipment.
    • I authorize release of all medical records needed in relation to the above referenced equipment.
    • I request that a payment be made to Provider by my insurance company, Medicaid, Medicare or government benefits.