Patient Information Intake Form


Doctor Info.


Private Insurance

Rehab and Mobility Systems ad reviewed the admission package with me and specifically reviewed and left me a copy of the following information: 

  • HIPPA/Release of information 
  • Privacy policies (and contact information for complaints)
  • Rights & Responsibilites 
  • Medicare Supplier Standards, if applicable 
  • Home Safety & Emergency Preparedness
  • Safety /  Functionality of the Equipment 
  • Demonstrated Proper Use of Equipment 
  • Warranty Information, if Applicable 
  • Important Telephone Numbers / After Hours Number 

EQUIPMENT WARRANTY INFORMATION: Every product sold or rented by our company carries a manufacturer's warranty. We Will notify all Medicare beneficiaries of the warranty coverage, and we will honor all warranties under applicable law. 
We Will repair or replace, free of charge, Medicare covered equipment that is under warranty. 
In addition, an owner's manual with warranty information will be provided to beneficiaries for all durable medical equipment where this manual is available. 

I authorize any holder of medical or other information about me to release to the Social Security Administration, Accrediting Agencies, CMS or its intermediates or its Carrier(s) any information needed for this or a related medical insurance benefits. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance either to myself of the party who accepts assignment.
I request that payment under the medical insurance program to be paid directly to Rehab and Mobility Systems for equipment and services furnished to me by Rehab and Mobility Systems during the time the equipment is in my possession. I agree that the rental equipment remains the property of Rehab and Mobility Systems and will be returned to them in good condition when no longer medical necessary. 
I also understand that Medicare may deny / reject the payment for the above equipment. In this case I will return the equipment or make suitable payment arrangements with Rehab and Mobility Systems.
Rehab and Mobility will not use my protected health information for marketing purposes.