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(214) 377-8144 sales@dermitech.com

 

After completing the consent form, we will contact you directly for more information.

 

Home Phototherapy Online Consent Form

1. Assignment of Medicare, Medicaid, Medicare Supplemental or other insurance benefits to Dermitech and/or Dermitech’s suppliers and/or our order fulfilling partners.
2. Direct billing to Medicare, Medicaid, Medicare Supplemental or other insurer(s).
3. Release of my medical information to Medicare, Medicaid, Medicare Supplemental or other insurers and their agents and assigns.
4. Dermitech or Dermitech’s order fulfilling partners to obtain medical or other information necessary in order to process my claim(s), including determining eligibility and seeking reimbursement for medical equipment provided.

HIPAA Statement and other disclosures

I confirm that the above information is accurate and complete to the best of my knowledge. I authorize Dermitech Phototherapy or its suppliers or order fulfilling partners to contact me by phone, email, postal mail or text regarding my medical equipment order. I authorize any holder of medical information about me to release to Dermitech, my physician(s), caregiver, CMS or its agents.

The encryption, and transmission of this information complies with HIPAA protocols.