Authorization of Benefits "*" indicates required fields Patient Name:**I request payment of authorized Medicare and/or insurance benefits to me or on my behalf for any services furnished by Trust Home Medical, LLC. I authorize any holder of medical information about me to release to Medicare, its agents, Insurance and Trust Home Medical any information needed to determine/bill these benefits. I authorize Trust Home Medical, LLC. to contact me for any reason. I or my caregiver can properly use the supplies requested. Patient responsible for payments not paid by Medicare and/or Insurance including deductibles and co-insurance. Please ship and bill Medicare and/or my insurance for my complete order I am requesting.Signature*Enter your email address here to receive a copy of your Authorization of Benefits* PhoneThis field is for validation purposes and should be left unchanged. 25891
