If you wish to have Intimate Image/Cancer Boutique bill Medicare, please read and sign the following:
I hereby authorize Intimate ImageŽ/Cancer Boutique to complete and file on my behalf any claim forms and other documentation, and to release any medical or other information necessary to process a claim for insurance or other reimbursement in connection with the items listed above. I represent to Intimate ImageŽ/Cancer Boutique that all of the above information is true and correct. I have paid Intimate ImageŽ/Cancer Boutique in full at the time of purchase.

I understand that my insurance may have a limit on products or dollar allowances for the items purchased. If any item I have chosen to purchase is in excess of or subject to a limited dollar allowance or is not covered under my insurance, I will be responsible for the difference between the cost of the items I have chosen and the amount covered by my insurance. I will pay any such amount in addition to any applicable deductible and co-payments.

I acknowledge that Intimate ImageŽ/Cancer Boutique has made no representation or warranty with respect to the availability or amount of any insurance payment or other reimbursement and that any insurance or Medicare claim submitted by Intimate Image/Cancer Boutique on my behalf is a service provided solely as convenience to me.

Signature:_________________________________________

Printed Signature ___________________________________

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