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Why we’re asking:
We use this form to collect your information only if you choose to be contacted about Medicare-related services, benefits, or care coordination. Submitting this form is optional.

Product:

First Name:

Last Name:

Date of Birth:

Zip Code:

Contact Preferences:

Phone call Email

Best Time to Contact You:

Morning Afternoon Evening

Phone Number:

Email Address:

Medicare Status:

Yes No Not sure

Contact Authorization:

I voluntarily authorize Juliart Medical, LLC, a Medicare-enrolled Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier, to contact me regarding Medicare-covered durable medical equipment and supplies, including but not limited to coverage verification, prescription or documentation requirements, delivery coordination, compliance follow-up, and other patient service–related communications using the contact methods I selected above.

HIPAA Authorization Disclosure
By checking this box, I authorize Juliart Medical, LLC to use and disclose my information only for communication purposes related to Medicare services.
I understand:

My information will be protected in accordance with HIPAA.
I am not required to sign this authorization to receive care or benefits.
I may revoke my consent at any time by contacting Juliart Medical, LLC by phone at (754) 240-4115 or email at customerservice@juliartmedicalllc.com.

I agree and give my permission to be contacted by Juliart Medical, LLC regarding Medicare-related information, services, or benefits using the contact methods I selected above.

Signature (Type Full Name):

Date:

This form complies with HIPAA privacy standards. Submitting this form does not enroll you in a Medicare plan. This is not a government website and is not affiliated with CMS or Medicare.

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