Financial Responsibility

I understand that I am financially responsible for all equipment, supplies, and services provided to me by High Country Oxygen. I have been informed of the charges associated with my equipment and services at or prior to delivery. I understand that my financial responsibility includes any deductibles, copayments, coinsurance amounts, and any charges not covered by my insurance or other third-party payor. If my insurance or other payor denies coverage for any reason, I understand that I may be responsible for the full cost of the equipment and services provided. I agree to pay any balance due promptly upon receipt of an invoice from High Country Oxygen. I understand that High Country Oxygen will notify me of any changes in payment information as soon as possible, but no later than 30 days after becoming aware of the change. If I am unable to pay for services, I understand that I may request a financial hardship evaluation. I understand that rental equipment remains the property of High Country Oxygen and must be returned at the end of the rental period or when no longer needed. I may be held financially responsible for equipment that is lost, stolen, or damaged beyond normal wear and tear while in my possession.

Assignment of Benefits

I authorize payment of medical benefits directly to High Country Oxygen for all equipment, supplies, and services furnished to me. I authorize High Country Oxygen to release any medical or other information necessary to process insurance claims or determine benefits payable for services rendered. This authorization includes the release of information to Medicare, Medicaid, and any other third-party payor as needed to facilitate payment. I certify that the information I have provided to High Country Oxygen regarding my insurance coverage is accurate and complete. I understand that any person who knowingly misrepresents or falsifies information in connection with a claim under Medicare or any other federal or state health care program may be subject to fines, penalties, or imprisonment under applicable law.