I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services and/or my private insurance, and its agents, any protected health information (PHI) or individually identifiable information (IIHI) needed to determine these benefits for related services. Please refer to TRS Care’s Notice of Privacy Practices for a more complete description of such users and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent.


I authorize TRS Care to file insurance claims with my insurance carrier for the products and services furnished by TRS Care. My insurance company, in lieu of reimbursing me directly, will pay to TRS Care any benefits for said product and services rendered. I understand that the amount billed to my insurance provider will be a standard rate negotiated and contracted by TRS Care and my insurance company. I agree to pay for services that are not covered or covered charges not paid in full including, but not limited to any co-payment, co-insurance and/or deductible, or charges not covered by insurance. 


For patients with financial need, we offer extended payment plans or financial assistance programs. Please ask to speak with one of our Patient Care Specialists to discuss your options.


I understand that TRS Care reserves the right to review all agreements on an individual basis to determine the continued acceptance of assignment for Medicare and/or any other medical insurance companies. In the event medical necessity no longer exists or my payer no longer deems my supplies to be covered, I understand I must return the unopened, reusable supplies to TRS Care so they may refund my insurance. I agree to call before returning the supplies.


I acknowledge receipt and understanding of my Patient/Client Bill of Rights, Medicare DMEPOS Supplier Standards, and Notice of Privacy Practices that I received as part of my supply order and understand that I may also view a copy of these documents at I also acknowledge that I have received and/or will receive training on the use of all products I order from TRS Care. In addition, I agree that TRS Care may contact me in the future, via telephone, email, instant messaging, mail or other means of communication, regarding ordering medical supplies.

Note: If the patient is physically or mentally unable to sign, a representative may sign on the patient’s behalf. In addition, the representative’s signature, date signed, representative's name (print), address, relationship to the patient and reason why the patient cannot sign must be listed.

I understand that I may revoke this consent in writing; however, my revocation will not apply to information already used or released in reliance on this consent. I agree that a copy of this consent may be used in place of the original. I also understand that by refusing to sign this consent or revoking this consent, this organization may not be able to provide services to me.

My signature on the Qualify Through Insurance Form indicates that I understand and accept the content on this form.

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