Skip to Content
Close Icon

Customer Intake Form

As a customer of Health Aid of Ohio, we'd like to obtain your consent to release health information to your insurance company, on your behalf, for the billing of the equipment ordered by your clinician. Without this information, we are unable to process your order. Should you have any questions, please contact Customer Service at (216) 252-3900 or (800) 762-5438.

 
  • * - Indicates required fields

  • Customer Information

  • By clicking "Agree", I indicate that: I have been provided with information with regards to how to reach Health Aid for assistance, the Return Policy, Perception of Care and Complaint Process, customer Rights & Responsibilities, Medicare Supplier Standards, and Notice of Privacy. I understand that this information is also available at www.healthaidofohio.com

  • NOTE: If the customer is physically or mentally unable to sign, a representative may sign on the customer’s behalf. In addition, the representative’s signature, date signed, representative’s name, address, relationship to customer and reason why the customer can’t sign must be listed below.

  • Representative Information

  • By signing below, I am agreeing to the terms stated in the Assignment of Benefits, Information Release and customer Agreement. I also understand that if a customer has received the same or similar equipment in the past, this equipment may not be covered by the customers insurer.

  • PLEASE REVIEW THE FOLLOWING, INDICATE THAT YOU HAVE RECEIVED THIS INFORMATION AND PROVIDE YOUR SIGNATURE TO BEGIN PROCESSING YOUR ORDER. THIS INFORMATION IS AVAILABLE ON THE HEALTH AID OF OHIO WEBSITE AT www.healthaidofohio.com.

  • Client Info

    Customer Bill of Rights

    Customer Responsibilities

    Supplier Standards
    The products and/or services provided to you by (supplier legal business name or DBA) are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c).These standards concern business professional and operational matters (e.g. Honoring warranties and hours of operation).The full text of these standards can be obtained at http://www.ecfr.gov request we will furnish you a written copy of the standards

    Health Aid of Ohio Notices of Privacy Practices

    Disclosure of Your Identifiable Health Information

    Your Rights

  • By Clicking Agree, I indicate that:
    I have been provided with information with regards to how to reach Health Aid for assistance, the Return Policy, Equipment Warranty Information, Medicare Capped Rental and Purchase Information, Perception of Care and Complaint Process, Patient Rights & Responsibilities, Medicare Supplier Standards, and Notice of Privacy. I understand that this information is also available at www.healthaidofohio.com

  • By signing below, I am agreeing to the terms stated in the Assignment of Benefits, Information Release and Patient Agreement. I also understand that if a patient has received the same or similar equipment in the past, this equipment may not be covered by the patients insurer.