PATIENT CONSENT FORM

Wellstart’s Patient Consent and Assignment of Benefits Form acknowledges that you understand certain required regulatory notifications and allows our Company to bill your insurance for payment of benefits. The form also will allow us to speak to your physician or other provider about processing your order and also provides a place for you to add or update your account information.

To download a PDF version of our Patient Consent and Assignment of Benefits Form, please click on the link below.

Please complete, sign, date, and return this form to Wellstart. You may send this form back to us in the mail, fax a copy over, or email it to us at:

Wellstart Medical, LLC
1669 SE South Niemeyer Cir, Unit 110
Port St. Lucie, FL 34952
(800) 971-3199 (Fax)
customerservice@wellstartmedical.com

If you have any questions about the form you may reach a customer care representative at (800) 978-7599