Delivery Notices (Reference)
Reference document of the delivery notices listed on your original delivery ticket, including returns, discrepancies, benefits, and payment authorizations.
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Table of Contents
The below documentation can also be found at the bottom of your original delivery ticket that you received (and signed) either during your in-person equipment setup or electronically if you received your equipment in the mail. It has been posted here for your convenience. A signed copy can be requested by contacting MedCare.
Returns or Discrepancies
Please notify of any shortage or discrepancies within five (5) days of receipt of goods or no credit will be allowed. Bathroom accessories and products cannot be returned after one (1) day of receipt. MERCHANDISE CONTAINED IN THIS SHIPMENT HAS BEEN CAREFULLY COUNTED AND CHECKED. I ACKNOWLEDGE RECEIPT OF EQUIPMENT AND/OR SUPPLIES LISTED ON THIS ORDER. PLEASE CALL OR WRITE REFERRING TO YOUR ACCOUNT NUMBER IN THE EVENT OF ANY DISCREPANCIES.
Assignment of Benefits
I request that payment of Medicare, Medicaid or other benefits be made on my behalf to the above company for products and services that they have provided for me. I further authorize a copy of this agreement to be used in place of the original and authorize any holder of medical information about me to release to the above company, Centers of Medicare and Medicaid Services and its agents or others any information needed to determine eligibility or reimbursement. I agree to pay all amounts that are not covered by my insurer(s) and for which I am responsible. I do understand that there are deductibles and co-pays that are my responsibility to pay.
I understand that MedCare's financial policy requires that I maintain a form of payment on file to pay for any charges not covered by my health insurance policy. The deductible and/or coinsurance charge amount is determined after your insurance company has adjudicated the claim for the items you are receiving. I authorize MedCare to execute transactions on this account. I understand that the use of this photocopy or fax of this agreement will serve as an original, and this payment authorization cannot be revoked unless done so in a 30-day written notice and management approval.
You will receive notification of the statement balance prior to the transaction. The charge will appear on your statement as MedCare Equipment Company.
Failure to pay for equipment will result in return of equipment and/or sent to collection agency for any unpaid balances.
If you would like to change or update your payment method, please contact our billing department at 724-850-6913 Monday – Friday 8:00AM – 4:30PM.
MedCare as the authorized designee certifies the patient/authorized agent has received and reviewed a copy of the Patient Information Guide and read the Patient Bill of Rights and Responsibilities as well as the Medicare Supplier Standards within. The undersigned certifies that he is the patient, or duly authorized as the patient’s general agent, to execute the above and accept its terms.