Equipment rental and claim submittal Forms

Please use the following forms complete your rental and for submission to your Insurance provider.

Forms Package	This is a single file with all of the forms listed below: Terms and Conditions Advanced Beneficiary Notice Release of Information Contact Sheet

Terms and Conditions	States that you accept the terms and conditions of the rental agreement.

Advanced Beneficiary Notice	States that you understand that Medicare does not provide coverage for the rental equipment.

Release of Information	Release of personal medical information according to standards of HIPAA.

Contact Sheet	This will be required if you are returning forms via fax. It also includes the phone and extensions of your personal care consultants.

OakWorks Leasing™ is proud to be the exclusive provider of
OAKWORKS^® Vitrectomy Face Down Recovery equipment

Forms Package