Patient Consent Form

This form gives us permission to bill your insurance for payment of benefits to Edgepark and allows us to contact your physician or other provider for information required to process your order.

Click the link below to download this from. Please note, this form is in PDF format, and Adobe® Acrobat or Adobe®  Reader® is required to view the document.

Patient Consent Form

Please print and sign this form in order to expedite the billing process. This form can be returned to: 

Edgepark Medical Supplies
1810 Summit Commerce Park
Twinsburg, OH 44087.

Or, you may scan and upload your signed form via the Web site at our Document Upload page.

The Patient Consent Form makes reference to the Patient/Client Bill of Rights, Medicare Supplier Guide and Notice of Privacy Practices.