Consent Form

I voluntarily select Shapiro Z Enterprise Inc., DBA Alina Medical Supply, as my supplier for the equipment and/or supplies prescribed for me. Should I decide to use a different supplier in the future, I will notify Alina Medical Supply, and any pending orders or prescriptions may be transferred to the provider of my choice. I understand that I have the right to choose any qualified provider of durable medical equipment and medical supplies.*

I authorize the release of my medical records, documentation, or other information necessary to process claims, verify medical necessity, obtain authorization, or secure payment for the equipment and supplies provided to me.*

I further authorize my insurance company, Medicare, Medicaid, or any other third-party payer to make payment directly to Shapiro Z Enterprise Inc., DBA Alina Medical Supply for covered equipment, supplies, and related services furnished to me. I understand that Alina Medical Supply will submit claims to my insurance carrier on my behalf for the equipment and supplies listed on the delivery receipt, or other applicable documentation.*

I authorize Shapiro Z Enterprise Inc., DBA Alina Medical Supply, to contact me by telephone and/or text message at the phone number(s) I provide regarding my orders, prescription status, insurance verification, prior authorizations, deliveries, refills, billing, and other matters related to the equipment and services provided to me. Standard message and data rates may apply.*

I acknowledge that I am financially responsible for any applicable deductibles, copayments, coinsurance amounts, non-covered services, or charges not paid by my insurance plan. I understand that ownership of purchased equipment transfers to me once payment has been made by my insurance carrier and/or by me, as applicable. Ownership of the equipment is not affected by future changes in insurance coverage, therapy compliance, or treatment status.*

I acknowledge that all equipment and supplies provided are non-returnable and non- refundable, except in the event of a manufacturer defect.*

By signing below, I confirm that I have read, understand, and agree to the terms outlined above.