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FINANCIAL RESPONSIBILITY AGREEMENT

Crossroads Medical Supply, LLC

Date of Birth:
Month
Day
Year

Assignment of Benefits

I authorize Crossroads Medical Supply, LLC to bill my insurance on my behalf and assign payment directly to Crossroads Medical Supply, LLC for products and services provided. I understand this authorization remains in effect until revoked in writing.

Financial Responsibility

I understand that I am ultimately responsible for all charges related to equipment, supplies, and services provided, including but not limited to: 

  • Deductibles

  • Copayments

  • Coinsurance 

  • Non-covered items

  • Services denied by insurance for any reason

If my insurance does not pay, I agree to pay the full balance.

Medicare & Insurance Compliance (If Applicable)

I understand that: 

  • Certain items require documentation of medical necessity 

  • My physician must provide required orders and records

  • My continued eligibility for coverage depends on compliance with payer requirements

For CPAP and similar equipment, I understand: 

  • Usage/compliance may be monitored

  • Failure to meet compliance requirements may result in denial of coverage

I agree to cooperate with all documentation and compliance requests.

CPAP & CGM Resupply Authorization

If enrolled in a resupply program, I acknowledge: 

  • Supplies will be shipped based on insurance guidelines and medical necessity 

  • I must confirm continued use and need when requested 

  • I will notify Crossroads Medical Supply of:

    • Changes in insurance o Changes in address 

    • Discontinuation of therapy

I understand I am responsible or all applicable patient balances for each shipment.

Auto-Ship Authorization

If I elect auto-ship services, I authorize Crossroads Medical Supply to: 

  • Ship supplies on a recurring basis

  • Charge my payment method on file and/or bill my insurance

I understand:

  • I may cancel or modify auto-ship at any time with reasonable notice 

  • Charges may occur for shipments processed prior to cancellation

Rental Equipment Responsibility

For rental equipment, I understand: 

  • Equipment remains the property of Crossroads Medical Supply unless purchased

  • I am responsible for: 

    • Proper use and care

    • Loss, theft, or damage beyond normal wear and tear

Failure to return equipment may result in additional charges.

Returns & Non-Returnable Items

I understand that: 

  • Certain medical items cannot be returned due to hygiene regulations 

  • Approved returns must be unused and in original condition 

  • Restocking fees may apply

Custom and special-order items are non-refundable.

Payment Terms

I agree to:

  • Pay all balances upon receipt unless otherwise arranged

  • Keep a valid payment method on file if requested I authorize

Crossroads Medical Supply to charge my card for:

  • Outstanding balances 

  • Copayments and coinsurance 

  • Failed insurance claims

Delinquent Accounts & Collections

If my account becomes past due, I understand that: 

  • Services and shipments may be delayed or suspended 

  • My account may be sent to collections

I agree to pay all reasonable costs of collection, including: 

  • Collection agency fees

  • Attorney’s fees (as permitted under Texas law)

Returned Payments

I understand that fees may apply for: 

  • Returned checks 

  • Failed credit/debit card transactions

Communication Authorization

I consent to receive communications from Crossroads Medical Supply, including: 

  • Phone calls 

  • Emails 

  • Text messages

Related to: 

  • Orders 

  • Billing 

  • Resupply reminders 

  • Account notifications

(Standard message and data rates may apply.)

Acknowledgment & Signature

By signing below, I acknowledge that: 

  • I have read and understand this Financial Responsibility Agreement

  • I agree to all terms outlined above 

  • I have had the opportunity to ask questions

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