Fifty 50 Medical

Print this page out and call Customer Service at 1-800-746-7505 to submit over the phone or fax.

Patient Information:


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Patient First Name Patient Middle Name Patient Last Name
Patient Subscriber ID Patient DOB(MMDDYYYY) Patient Gender
Street Address 1
Street Address 2
 
Patient City Patient State Patient Zip Code
Patient Home Phone Patient Work Phone  
 
Patient Email Guardian First Name Guardian Last Name
What Type of Diabetes? 
How many times per day do you test?
 
Does Patient use an insulin pump? (Y or N) 
If patient uses an insulin pump, what is the pump type?
Does Patient Have Prescriptions? 

Doctor Information:


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Doctor First Name Doctor Last Name  
 
Doctor Street Address 1
Street Address 2
 
Doctor City Doctor State Doctor Zip Code
Doctor Office Phone Doctor Office Fax  


Policy Holder


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Policy Holder First Name Policy Holder Last Name Relationship to Patient
Policy Holder Subscriber ID Policy Holder DOB (MMDDYYYY) Policy Holder Employer


Insurance Company


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Insurance Company
Street Address 1
Street Address 2
Insurance City Insurance State Insurance Zip
Insurance Phone Insurance Fax  
 
Insurance Group Number
Insurance Policy Number / Insurance ID Number

Prescription Information

Do you pay a copay at the pharmacy?
If you pay a copay, what is the pharmacy help desk phone number
Prescription Name Prescription Phone Number
RX Group Number RX ID Number
RX Bin RX Copay (If Known)
Prescription Carrier (Usually found on your insurance card)


Medicare


Bold = Required if box checked

Check if you have Medicare
 
FIFTY 50 only accepts Medicade for Texas. Medicare Advantage Plans are accepted for all states.
Medicare ID Number Medicare Relationship Part B Effective Date (MMDDYYYY)
Is Medicare Primary?
 

Supplemental Carrier Information


Bold = Required if box checked

Check if you have Supplemental Insurance

Supplemental Carrier Name
Supplemental Carrier Phone Supplemental Carrier Fax
Supplemental Carrier ID Number
Supplemental Carrier Policy Number
Supplemental Carrier Group Number
Supplemental Carrier Effective Date (MMDDYYYY)

Payment for Services Notice

In accordance with the receipt of services provided by Fifty50 Medical, I hereby agree that my insurance benefits be paid directly to Fifty50 Medical. In addition, I agree to cooperate fully to secure such payment and I authorize the release of information required to file an insurance claim on my behalf from the prescribing physician, hospital and to the insurance carrier. In the event my insurance refuses reimbursement, I agree to be personally liable for all pharmacy charges incurred. I also understand FIFTY50 Medical requires a credit card on file for insurance copay and charges. My credit card information has been provided. I have read and I understand all of the above.

ACKNOWLEDGEMENT
I, acknowledge the above Payment for Services Notice.*

Name on Card:
Billing Zipcode:
Credit Card #:
Expiration Date: MM/YYYY
CVV2:


HIPAA Agreement


THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY.

The Privacy Act is in place in order to protect patient's medical records and other health information provided to health plans, doctors, hospitals, and other healthcare providers and took effect on April 14, 2003. Developed by the Department of Health and Human Services (HHS), these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed. They represent a uniform, federal floor of privacy protections for consumers.

Congress called on HHS to issue patient privacy protections as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA included provisions designed to encourage electronic transactions and also required new safeguards to protect the security and confidentiality of health information. This covers us as a healthcare provider who conducts certain financial and administrative transactions (i.e. enrollment, billing, eligibility information, etc.) electronically.

This policy ensures privacy protections for patients by limiting the ways that health plans, pharmacies, doctors, hospitals and other covered entities can use patients' personal medical information, whether it is on paper, in computers, or communicated orally.

Fifty 50 Medical may use your personal medical information for the following reasons:

FOR TREATMENT: We may use medical information about you to provide you with medical supplies. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you.

FOR PAYMENT: We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on, or accompanying the bill may include your medical information.

ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment and/or payment, we may use and disclose medical information for the following purposes:

In our facility: Unless you notify us that you object; your needed medical information, name, address, phone numbers, insurance information, date of birth, payment information, and/or social security information will be stored in our systems. As well as any other personal information that you have informed us of.

Notification: We may use and disclose medical information to notify or help notify: your guardian, family members, doctors, nurses, or other persons responsible for your care. As always, we will also use our best professional judgment to make decisions in your best interest about allowing someone to pick up medication, medical supplies, or medical information for you.

Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities responsible for preventing or controlling disease, injury, disability, child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration (FDA) for purposes of reporting adverse events associated with product defects or problems.

Alternative and Additional Services: We may use and disclose medical information to furnish you with information about health-related benefits, and services that may be of interest to you, and/or send you catalogues, postcards, or flyers containing condition related product advertisements.

In accordance with the receipt of services provided by Fifty50 Medical, I hereby agree that my insurance benefits be paid directly to Fifty50 Medical. In addition, I agree to cooperate fully to secure such payment and I authorize the release of information required to file an insurance claim on my behalf from the prescribing physician, hospital and to the insurance carrier. In the event my insurance refuses reimbursement, I agree to be personally liable for all pharmacy charges incurred. I also understand FIFTY50 Medical requires a credit card on file for insurance copay and charges. This can be given at checkout. I have read and I understand all of the above.

ACKNOWLEDGEMENT
I, acknowledge the above notice of privacy practices and agree to allow Fifty 50 Medical to use my information as listed above.*