Assignment of Benefits Agreement

I, the undersigned, irrevocably authorize assignments of and direct payments for insurance benefits to SunMED Medical Systems, LLC for the medical equipment furnished to me by SunMED Medical Systems, LLC.

I further agree and acknowledge that my signature on this document authorizes SunMED Medical Systems, LLC to obtain and release any medical and bill ing information to my insurance company necessary to process my claim(s), including determining eligibility and seeking reimbursement for medical equipment provided.

I irrevocably request that payment of authorized benefits be made to SunMED Medical Systems, LLC on my behalf, for medical equipment furnished to me by SunMED Medical Systems, LLC. In the event that my insurance company does not pay for any reason, I will pay SunMED Medical Systems, LLC directly upon receipt of invoice within 14 days.

In the event that my insurance carrier reimburses me instead of SunMED Medical Systems, LLC, I w ill rem it a copy of the explanation of benefits, and sign the check over to SunMED within 2 weeks or provide payment in full by credit card or personal check. I understand that if payment is not forwarded, fourteen days from the issue date of the check interest of 19% per year will begin to accrue. If payment is not received in 30 days my account will be sent to SunMED Medical Systems, LLC’s collections attorney and payment, interest, and attorney fees will be my responsibility.

I irrevocably acknowledge that my signature on this document represents that I will be responsible for full payment of equipment. I am aware that SunMED Medical Systems, LLC will bill my insurance carrier as a courtesy and as a result, I am responsible for my insurance deductible, and/or co-payment/co-insurance, and/or patient responsibility. I agree to be responsible for all costs of collection, including reasonable legal fees incurred by SunMED Medical Systems, LLC.

I will notify SunMED Medical Systems, LLC prior to any changes in my insurance coverage. In addition, the signature below acknowledges that I have received a summary of SunMED Medical Systems Notice of Privacy Practices and may request a detailed version at any time.

About SunMED

SunMED Medical Solutions is a national provider of specialty medical equipment and enhanced clinical support for the treatment of patients of all ages and conditions. We provide the most clinically superior brands and sought-after models of each product we carry.

SunMED was founded in 2002. Located in Marlton, New Jersey (in the Philadelphia area), our over 150 employees serve patients nationwide. We are a Medicare provider, hold over 200 insurance company contracts, multiple workers compensation contracts and we are a Medicaid provider in 20 states.

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