I hereby authorize The Essential Woman 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 The Essential Woman Boutique that all of the above information is true and correct.

I understand that after The Essential Woman Boutique has received the reimbursement from my insurance company or Medicare and my supplemental, I may be billed for any deductible or co-payments.

I acknowledge that The Essential Woman 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 The Essential Woman Boutique on my behalf is a service provided solely as convenience to me.