Please read our FAQ’s before filling out the form.
Please note that if you place an order with multiple vendors, out-of-pocket costs may be incurred.

We participate with the following Medicaid plans: CO, NC, SC, CA, OK, NM, NV.

PLEASE NOTE, YOUR ORDER IS INCOMPLETE UNTIL:

This completed and signed request is submitted to MomWell by clicking on the submission button below.

Your signature on this document allows Synergy DMEPOS, the MomWell Care Kit provider, to perform the following steps:
- Verify your insurance eligibility and benefits
- Reach out to your provider to complete and sign the prescription form/provider order. (This kit includes medical grade devices that require a prescription.) If there are any insurance coverage issues, we will reach out to you directly.

Synergy DMEPOS will NOT ship items without first notifying you of any costs.

Please Read and Accept below

I agree to accept DME product(s), per my provider order, from Synergy DMEPOS/MedSource and consent to the submission of the related claims by Synergy DMEPOS, MedSource, and/or affiliate subcontracted partners requesting that the payment of authorized government and/or other commercial third-party insurance benefits, including supplemental and co-insurance policies be made on my behalf directly to Synergy DMEPOS/MedSource. I agree to provide all documents and information necessary for direct payment from Medicare, Medicaid, or other commercial third-party payers and hereby, authorize the release of my medical information to determine and obtain insurance benefits for products and services provided to me by Synergy DMEPOS, MedSource, and/or a subcontracted provider. Should I receive payment directly for products and services provided by Synergy DMEPOS/MedSource, I agree to immediately transfer such payments to Synergy DMEPOS/MedSource. I authorize Synergy DMEPOS/MedSource to appeal denied insurance authorizations and/or benefits. Services/supplies may be provided by any of Synergy’s family of companies, including Synergy DMEPOS, MedSource, and certain other affiliates. Financial Responsibility: I understand and agree that: (1) I am financially responsible to Synergy DMEPOS/MedSource for payment of applicable deductibles and coinsurance and any other (co-sharing) amounts that are not covered by my insurance unless otherwise provided by law, regulation, or DME Supplier contractual relationships; (2) the actual amount I will owe depends on my insurance plan, whether my deductible has been reached, and whether I have secondary coverage; (3) if I have supplemental insurance, that plan may cover my coinsurance obligation in whole or in part; (4) should my insurance deny coverage of the item(s) ordered by my physician, the financial responsibility shall be mine, and I will receive a statement reflecting the amount due by me. In this instance, I will be notified in advance of the product distribution to allow for my refusal of such item. Email Acknowledgment: By providing my email address, I authorize Synergy DMEPOS/MedSource to contact me regarding care and services related to the product I have approved and that it will not be used for any other purpose. Portions of the correspondence may not by encrypted; therefore, Synergy DMEPOS/MedSource cannot ensure or warrant the security of any information transmitted or received by email. For any questions regarding my rights, I will refer to Synergy DMEPOS’ Notice of Privacy Practices and Patient Bill of Rights. I understand that I have access to the CMS DMEPOS standards via: DMEPOSSupplierStandards.pdf (cms.gov).

As an individual receiving services from the Provider, you have the following rights: Be fully informed in advance about care/service to be provided, including the disciplines that furnish care and the frequency of visits, as well as any medications to the plan of care Be informed, both orally and in writing, in advance of care being provided, of the charges, including payment for care/service expected from third parties and any charges for which the client/patient will be responsible Receive information about the scope of services that the organization will provide and specific limitations on those services Participate in the development and periodic revision of the plan of care Have one’s property and person treated with respect, consideration, and recognition of client/patient dignity and individuality Be able to identify visitation personnel members through proper identification Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of client/patient property Voice grievances/complaints regarding treatment of care, lack of respect of property or recommend changes in policy, personnel, or care/service without restraint, coercion, discrimination, or reprisal Have grievances/complaints regarding treatment of care that is (or fails to be) furnished, or lack of respect of property investigated Confidentiality and privacy of all information contained in the client/patient record and of Protected Health Information Be advised on the Provider’s policies and procedures regarding disclosure of clinical records Choose a health care provider, including choosing an attending physician, if applicable Receive appropriate care without discrimination in accordance with physician orders, if applicable Be informed of any financial benefits when referred to an organization Be fully informed of one’s responsibilities

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.

We are required by law to maintain the privacy and security of your protected health information (PHI) and to provide you with a Notice of our legal duties and privacy practices with respect to protected health information. This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to your PHI. “Protected health information” is information about you, including basic demographic information, that may identify you and that relates to your past, present, or future physical or mental health/condition, and related health care services. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this Notice and give you a copy of it. We will not use or share your information, other than as described in the Notice, unless you tell us that we can, in writing. If you tell us that we can, you may change your mind at any time, in writing. We reserve the right to change our practices and this Notice, and to make the new Notice effective for all PHI we maintain. The new Notice and effective date will be available on our website. Upon request, we will provide you with a revised Notice. OUR USES AND DISCLOSURES – How do we typically use or share your health information? We do so in the following ways: Treat You – We can use your health information and share it with other professionals who are treating you. Example: Information obtained by our representative will be recorded in your records and used to determine suitability for the product, fitting, and to provide instruction regarding appropriate use of the product. We may also disclose PHI to doctors, nurses, or other personnel outside our office who need the information to provide you with medical care. Run our Organization – We can use and share your health information to run our business, improve your care, and contact you when necessary. Example: We use health information about you for operational purposes. These uses and disclosures are necessary to make sure that patients receive quality products and services and to manage our organization. Bill for Your Services – We can use and share your health information to bill and receive payment from health plans or other entities providing treatment and service. Example: We provide information about you as well as your diagnosis and product supplied to your health insurance plan so they will pay for your services. Sale of the Business – If we decide to sell, transfer, or merge all or part of our business with another entity, we may share your PHI with the new owners. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We must meet many conditions in the law before we can share your information for these purposes. Help with public health and safety issues. We can share information about you for certain situation such as: Preventing diseaseMonitoring the performance of a product after it has been approved for use by the public Helping with product recallsReporting suspected abuse, neglect, or domestic violence Reporting adverse eventsPreventing or reducing a serious threat to anyone’s health or safety Do research – We can use or share your information for health research. Comply With the Law – We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if they want to see that we are complying with federal privacy law.