+ FinalMedic Inc.

Assignment of Benefits — Universal Intake

Form FM-AOB-001 · 2026

1. Patient / Insured Information

Full legal name * Date of birth *

Street address * City *

Province * Postal code * Phone * Email

Preferred language Gender (if required by insurer)

2. Primary Insurance

Insurer name * Plan type

Policy / Plan # * Group / Contract # Certificate / Member ID *

Plan sponsor / Employer name Relationship to plan member *

Fill the following only if you are NOT the plan member yourself:

Plan member full name Plan member date of birth

3. Secondary Insurance (if applicable)

Secondary insurer name Policy / Plan # Certificate / Member ID

4. Supplies & Prescribing Practitioner

Prescribing practitioner name Practitioner phone Prescription date

Diagnosis or claim reason (optional but speeds approval)

Authorization duration

5. Authorization & Consent

By signing below, I confirm and agree to all of the following:

I assign and transfer to FinalMedic Inc. all rights, title, and interest in any insurance benefits payable in respect of medical supplies provided to me, up to the amount billed. I authorize my insurer(s) to pay FinalMedic Inc. directly.
I authorize my insurer(s), plan administrator(s), and prescribing practitioner(s) to release to FinalMedic Inc. any information needed to verify coverage, adjudicate claims, or coordinate benefits, including policy, group, and member details.
I understand that I remain personally responsible for any portion of the cost not paid by my insurer(s), including deductibles, co-insurance, or amounts above plan maximums.
This authorization remains in effect until I revoke it in writing. I may revoke it at any time by sending written notice to FinalMedic Inc.
I agree that a photocopy, scan, or electronic copy of this signed form has the same effect as the original.
I certify that the information I have provided is accurate and complete to the best of my knowledge.

6. Signature

Printed name * Date *

Signature of insured (or legal representative)

If signed by a legal representative (parent, guardian, power of attorney):

Representative name Relationship / authority

7. Provider Information (pre-filled by FinalMedic)

Provider: FinalMedic Inc.

Address: Saint-Césaire, Québec, Canada

Phone: 1-800-295-8579

Email: info@finalmedic.ca

GST/HST #:

QST #:

Date received (staff) Staff initials Client file #

Universal Assignment of Benefits — Intake Form