Hock's Pharmacy
535 SOUTH DIXIE DRIVE
VANDALIA, OHIO 45377
800 866 4997 voice      937 898 9340 fax
IMPORTANT
This AOB form is required to bill on your behalf !

Please complete, sign and return this form today !

ASSIGNMENT OF BENEFITS---Print This Form

This form is required to bill Medicare on your behalf.
Without this signed form in our files, we cannot fulfill your order.
Please complete, sign and return this form immediately.

 

 

My signature below authorizes each of the following:

(a)

Assignment of Medicare, Medicaid, Medicare Supplemental and/or other insurance benefits to Hock's Pharmacy for medical supplies and/or medication(s) furnished to me by Hock's Pharmacy.

 

 

(b)

Direct billing to Medicare, Medicaid, Medicare Supplemental and/or other
insurer(s).

 

 

(c)

Release of my medical information to Medicare, Medicaid, Medicare Supplemental and/or other insurers and their agents and assigns.

 

 

(d)

Hock's Pharmacy to obtain medical or other information necessary in order to process my claim(s), including determining eligibility and seeking reimbursement for medical supplies and/or medication(s) provided.

 

 

(e)

Hock's Pharmacy to contact me by telephone or mail regarding my medical supplies and/or medication(s) order.

 

 

I agree to pay all amounts not covered by Medicare and/or my insurer(s) for which I am responsible including, but not limited to, any unmet portion of Medicare's $100 annual deductible. I also understand and agree that if I join a Medicare HMO, I am fully responsible for all uncovered purchases.

PRINT YOUR NAME HERE_______________________________________
  
SIGN YOUR NAME HERE________________________________________
  
TELEPHONE NUMBER__________________________________________
  
YOUR MEDICARE NUMBER______________________________________