To continue delivering your medical supply services, we kindly ask that you complete the Assignment of Benefits form below. Without this signed form, we will be unable to fulfill your medical supply request due to required compliance with your insurance provider.
To get started, please complete and sign the below Assignment of Benefit form.
This form is easily filled out via mobile or desktop device and electronically submitted through the 'Fill Out Form' button below.
If you prefer, you can also fax or mail the completed form using the following information:
Fax: (512) 421-7181
Mailing Address: National Seating & Mobility
8 N 21st St, Temple, TX 76504