Terms & Conditions

Financial Responsibility

I have requested professional services from AAA DME LLC DBA Help To Momson behalf of myself and/or my dependents and understand that by making this request; I am responsible for all charges incurred during the course of said services. I understand that all fees for said services are due and payable on the date services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate 
statement unless other arrangements have been made in advance.

Assignment of Insurance Benefits

I hereby assign all applicable health insurance benefits to which I and/or my dependents are 
entitled to AAA DME LLC DBA Help To Moms I certify that the health insurance information that I provided 
to AAA DME LLC DBA Help To Moms is accurate as of the date set forth below and that I am responsible for keeping it updated. I hereby authorize AAA DME LLC DBA Help To Moms . To submit claims, on my and/or my dependent’s behalf, 
to the benefit plan (or its administrator) listed on the current insurance card I provided to AAA DME LLC DBA Help To Moms in good faith. I also hereby instruct my benefit plan (or its administrator) to pay AAA DME LLC DBA Help To Moms directly for services rendered to me or my dependents. To the extent that my current policy prohibits direct payment to AAA DME LLC DBA Music City Med LLC, I hereby instruct and 
direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to myself and AAA DME LLC DBA Help To Moms upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its administrator) to make the check payable to me and mail it directly to AAA DME LLC DBA Help To Moms- 810 Dominican Drive, Nashville, TN, 37228.I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from AAA DME LLC DBA Help To Moms are paid in full. I also 
understand that I am responsible for all amounts not covered by my health insurance, including 
co-payments, co-insurance, and deductibles.

Disclosures

Authorization to Release Information

I hereby authorize AAA DME LLC DBA Help To Moms to: (1) release any information necessary to my health 
benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance 
claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing.

ERISA Authorization

I hereby designate, authorize, and convey to AAA DME LLC DBA Help To Moms. To the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan: (1) the right and ability to act on my behalf in connection with any claim, right, or cause in action that I may have under such insurance policy and/or benefit plan; and (2) the right and ability to act on my behalf to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan (including 
but not limited to, the right to act on my behalf in respect to a benefit plan governed by the 
provisions of ERISA as provided in 29 C.F.R. §2560.5031(b)(4) with respect to any healthcare expense incurred as a result of the services I received from AAA DME LLC DBA Help To Moms and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement,  and any other applicable remedy, including fines.