ASSIGNMENT OF BENEFITS

Before we ship your product(s), we need you to authorize DME, to provide products or services that were rendered and submit claims to your insurance company on your behalf.

I also authorize DME to request on my behalf all insurance information, prescriptions, benefits for products provided as well as to release my medical records to any person, organization, company and/or agency which may be involved in providing my care.

TERMS & CONDITIONS

DME SCOPE OF SERVICES

DME offers durable medical equipment to patients through their health insurance or retail. Our goal is to provide quality products and services to our customers. DME will use the least expensive and most appropriate method of delivery to ship covered equipment to customers.

AUTHORIZATION AND CONSENT

Statement to Permit Payment of Insurance Benefits to Provider, Physician and Patient. I request that payment of authorized Medicaid, Medicare and/or private insurance benefits be made to me or, on my behalf, to DME for any services or products furnished to me by DME. I authorize a copy of this agreement to be used in place of the original.

I further authorize any holder of medical information about me to release any information needed to determine eligibility or reimbursement to DME, my physician (s), caregiver, Centers for Medicare and Medicaid Services and its agents, my insurance company or others.

Optional Upgrade & Financial Responsibility Acknowledgment. I agree to pay all amounts not covered by my insurer(s), including any optional upgrade that I authorize and for which I am financially responsible. I understand that the credit card information I provided at the time of my order for an upgrade is an authorization hold to confirm that the account is active and funded. The funds will not be captured until the order is completed and shipped. I realize that there may be a time lag between when I am charged for my upgrade and when my product(s) ship. I understand that I will be refunded for the upgrade fee if I decide to cancel my order.

Additionally, I understand that I am financially responsible for any denied insurance claims resulting from having already received a breast pump or other related service prior to the one being billed for in this order.

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with the Privacy Rule of Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:

1. This authorization does not include disclosure of information relating to ALCOHOL AND DRUG ABUSE, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV RELATED INFORMATION.

2. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

3. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

4. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU, MY PHYSICIAN, TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN MY INSURER AND DME.

5. Name and telephone number of health provider/OB/GYN to release this information will be as you have supplied in the form above.

6. This information will be faxed to: DME at (secure fax)

If you would like to learn more about your protected health information, please visit https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/privacy-practices-for-protected-health-information/index.html.

AS A PATIENT YOU HAVE THE FOLLOWING RIGHTS

To decide who provides your pregnancy supplies and/or equipment.
To receive the correctly prescribed service and/or equipment in a professional manner without discrimination of age, race, sex, religion, ethnic origin, sexual preference or physical or mental handicap.
To be promptly informed if the prescribed care or services are not within the scope, mission, or philosophy of Provider, and therefore are provided with transfer assistance to an appropriate care or service organization.
To be treated with kindness, courtesy, respect, and without neglect or abuse, either physically or mentally.
To have your privacy respected at all times.
To be provided with adequate information to give your informed consent for the start of service, the continuation of service, the transfer of service to another provider, or the termination of service.
To receive upon request, complete and up-to-date information relative to your condition, treatment, alternative treatments, and risks of treatment within our responsibilities of medical.
To receive treatment and services within the scope of your health care plan, promptly and professionally, while being thoroughly informed as to Provider policies, procedures and charges.
To refuse care, within the boundaries set by law, and receive professional information relative to the ramifications or consequences that will or may result due to such refusal.
To request and receive data regarding services or costs thereof privately and with confidentiality.
To request and receive the opportunity to examine or review your medical records.
To be involved, as appropriate, in discussions and resolutions of conflicts and ethical issues related to your care.
To be informed of any experimental or investigational studies that are involved in your care and to be provided the right to refuse any such activity.
To expect that all information received by this organization will be kept confidential and will not be released without written consent.
To have the right to access, request amendment to, and receive an accounting of disclosures regarding health information as permitted under applicable law

THE DMEPOS SUPPLIER STANDARDS

A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the supplier within 30 days.
An authorized individual (one whose signature is binding) must sign the application for billing privileges.
A supplier must fill orders form its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State Health Care Programs, or from any other Federal procurement or nonprocurement programs.
A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental
A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
A supplier must maintain a physical facility on an appropriate site.
A supplier must permit CMS, or its agents to conduct on‐site inspections to ascertain the supplier’s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation.
A supplier must maintain a primary business telephone in the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of beeper, answering machine or cell phone is prohibited.
A supplier must have comprehensive liability insurance in the amount of $300,000 that covers the supplier’s place of business and all customers and employees.
A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business.
A supplier is responsible for delivery and must instruct beneficiaries on use of Medicaid covered items, and maintain proof of delivery.
A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
A supplier must maintain and replace at no charge or repair directly, or through a contract with another company, Medicaid‐covered items it has rented to beneficiaries.
A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicaid‐covered item.
A supplier must not convey or resign a supplier number; the supplier may not sell or allow another entity to use its Medicaid billing number.
A supplier must have a complaint resolution protocol established to address Beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
A supplier must agree to furnish CMS any information required by Medicaid Statue and implementing regulations.
All suppliers must be accredited by a CMS‐approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals). Implementation Date – October 1, 2009.
All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
All supplier locations whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
Must meet the surety bond requirements specified in 42 C.F.R. 424.57 (c). Implementation date – May 4, 2009.
A supplier must obtain oxygen from a state‐licensed oxygen supplier.
A supplier must maintain ordering and referring documentation consistent with the provisions found in 42 C.F.R. 424.516 (f).
DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.
DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.

Complaints

If you have a complaint about the service received and/or personnel at DME then please contact us to formally file your complaint so that we can answer your concerns and continually improve our service.
You may also file a complaint to outside sources such as your insurance company, Medicare (800) 633‐4227 or BOC Accreditation by calling (877) 776-2200.

Equipment Warranty

Every product sold or rented through insurance carries at least a 1‐year manufacturer’s warranty. Specific warranty length and information is described in the manufacturer’s owner’s manual provided with each product.
DME will repair or replace, free of charge, equipment that is under warranty. In addition, an owner’s manual with warranty information will be provided to beneficiaries for all durable medical equipment where this manual is available.

Statement to Permit Payment of Medical Benefits

I understand that I am authorizing DME to provide breast pumps, supplies, and accessories to me.
I understand that I am giving DME permission to ask my insurance for payments for my medical care, including supplies and equipment.
I certify that the information provided by me in applying for payment under title XVIII (Medicare) of the Social Security Act or any other insurance benefits is true and correct.
I understand that Health Care Benefit Payee may need information about my medical condition to determine benefits related to “Company” services. I give permission for the release of medical or other information necessary to process the “Company” payment request.
I ask that payment of authorized Health Care Benefits be made on my behalf to DME for any services or items furnished to me.
I understand that if my insurance denies or challenges this claim for the prescribed supplies, I will be solely responsible for this claim.

Client Responsibility Waiver

Medicaid, Medicare or any other health insurance company will only pay for equipment and services that it determines to be “reasonable and necessary” (Section 1862(a)(I) of the Medicare law for Medicare). If your insurance determines that a particular service or piece of equipment is not “reasonable and necessary” under your insurance standards, your insurance company may deny payment for it. In the event that they do deny payment, you will be responsible for the reasonable and customary cost of the equipment or service.
I certify that I HAVE NOT RENTED SAME OR SIMILAR EQUIPMENT through Medicaid, Medicare or any other insurance, or If SAME OR SIMILAR equipment was rented, the equipment has been returned to the DME supplier. I also certify that Medicare is not paying service or maintenance charges for SAME OR SIMILAR equipment I use.
I certify that I HAVE NOT PURCHASED SAME OR SIMILAR equipment through Medicare, Medicaid or any other Insurance, or if I have purchased any equipment, documentation has been provided to DME.
I understand that most insurance will only cover one nebulizer every three years, and I understand that if my insurance denies or challenges this claim for SAME OR SIMILAR equipment being rented or purchased, I will be solely responsible for this claim.
If my insurance should deny payment for any reason other than the above stated reason, I will be solely responsible for this claim.
I will cover any and all additional charges involved in having the equipment returned.
DME reserves the right to have this agreement transferred over to another Medicare Supply or Pharmacy provider to provide the service.

Deductibles and Co‐Insurance

I understand that any annual deductible or co‐payments from my insurance are my responsibility unless covered by a secondary insurance policy.

Equipment Training ‐ A representative of DME or my doctor’s office has advised me of the following:

The proper and safe operation of the unit.
Basic maintenance of the unit.
That I must read and fully understand the owner’s manual that I have received before operating the unit.
You may contact us for additional training and support

Notice of Privacy Policy

(Patient)

To our patients: This notice describes how health information about you, as a patient of DME, may be used and disclosed. You will also find below, information on your rights and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

Our commitment to your privacy

DME is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information:

Use and disclosure of your health information in certain special circumstances

The following circumstances may require us to use or disclose your health information:

In the process of providing you services and in the claims submission to other Healthcare organizations for reimbursement.
To public health authorities and health oversight agencies that are authorized by law to collect information.
Lawsuits and similar proceedings in response to a court or administrative order.
If required to do so by a law enforcement official.
When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.
If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
To federal officials for intelligence and national security activities authorized by law.
To correctional institutions or law enforcement officials if you are an inmate or under the custody of law enforcement officials.
For Workers Compensation and similar programs.

Your rights regarding your health information

Communications. You can request that DME communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.
You can request a restriction in our use or disclosure of your health information for treatment, payment, or Healthcare operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient Medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to: (See DME information Below). You may ask us to amend your health information if you believe it is incorrect or incomplete and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to: (See DME Information Below) you must provide us with a reason that supports your request for amendment.
Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact: (See DME Information Below).
Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact: (See DME Information Below). All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

If you have any questions regarding this notice or our health information privacy policies, please contact (See DME Information Below).

DME