PATIENT AGREEMENTS

Through this web site tab, all new and current patient/customers of Patient Care Medical are informed of various policies and procedures regarding the Assignment of Benefits, Secondary Insurance and Co-pay, “Direct-to-Patient” payments, Patient Bill of Rights and Responsibilities, HIPAA and Supplier Standards.

These policies and procedures are detailed below.

AUTHORIZATION TO ASSIGN BENEFITS

I REQUEST PAYMENT OF AUTHORIZED Medicare, Medicaid, or Private Pay insurer benefits to me or on my behalf for any services furnished me by Respiratory Solutions, LLC, dba Patient Care Medical. I authorize any holder of medical information about me to release to Medicare, Medicaid or any applicable Private Pay insurer and its agents any information needed to determine these benefits or benefits for related services. 

SECONDARY INSURANCE AND CO-PAY

I understand that I am fully responsible for any secondary or co-pay amounts, which will vary from insurer to insurer. I acknowledge that I have discussed this with a representative from Respiratory Solutions, LLC, dba Patient Care Medical (RS/PCM), and that I have been explained my insurance benefits and the coverage it will provide. I also understand that if I do not have any secondary insurance of any type (Medicaid, AARP, etc.), and if the co-pay and/or deductibles will create a financial hardship for me, that RS/PCM will obtain additional information from me regarding my finances, which will be kept in the strictest confidence. This additional financial information could result in a hardship waiver of these costs, however there is no guarantee of such. 

PAYMENTS DIRECTLY TO BENEFICIARY

Blue Cross Blue Shield and other insurers will, under certain circumstances, send the reimbursement checks for product(s) provided directly to the beneficiary. I fully understand that this is an insurance formality and that these checks are the property of Respiratory Solutions, LLC, dba Patient Care Medical (RS/PCM). I understand that it is my responsibility to forward such reimbursement checks to RS/PCM immediately upon my receipt of the check. I understand that RS/PCM will accommodate this process by sending me a postage paid envelope to use in forwarding the check to them. Failure to forward such reimbursement check could result in collection activities, up to and including legal proceedings. 

PATIENT BILL OF RIGHTS AND RESPONSIBILITIES

You have the right to accurate and easily understood information about your health plan and benefits. You have the right to choose health care suppliers of your choosing based on your particular needs. You have the right to know all product options available to you for your specific condition. You have the right to have parents, family members, guardians, or others that you choose to speak for you if you cannot make your own decisions. You have the right to considerate, respectful, and confidential care from your medical product supplier. You have the right to non-discrimination of any type, regardless of race, ethnicity or any other factors. You have the right to a fair, fast, and objective review and resolution of any complaint you may have, and this complaint will be escalated to the highest level of the company, if necessary. You have the right to a full disclosure of all costs for the product(s) you are receiving, including insurance, secondary, co-pay and deductibles, prior to any commitment on your part. You have the right to cancel services at any time for any reason, as long as we are informed, either by phone or in writing, of this cancellation at least one week prior to your next scheduled delivery. 

You have the responsibility to provide complete and accurate information, including your full name, address, telephone, date of birth, insurance plan numbers and any other information required to provide you with the product(s) and/or services you have requested. You have the responsibility to report to RS/PCM any changes in your health care insurance coverage, change of physicians, change in your condition which may affect the supplies we provide to you, and any other changes that may influence our ability to be reimbursed for the products and services we provide. You have the responsibility to satisfy any deductible, secondary insurance or co-pay amounts unless alternative arrangements have been justified and accommodated.

HIPAA PRIVACY NOTICE

We are required by law to maintain the privacy of “protected health information”. “Protected health information” includes any identifiable information that we obtain from you or others that relates to your physical or mental health, the health care you have received, or the products we are providing to you. This notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of your protected health information. This notice also addresses the uses and disclosures we will make of your protected health information. All healthcare information obtained and kept by Respiratory Solutions, LLC, dba Patient Care Medical is stored electronically with the highest level of safeguards and protection available. Only authorized personnel can access this information and all employees of the company are required to sign a statement abiding them to the privacy of all protected health information. We only release this information as required to the applicable insurance carrier that is responsible for processing claims for the products we provide to you, and only upon their request to review such information. Should you desire to further restrict any disclosure of your protected health information you have the right to request such and we will do everything possible to accommodate you as long as this further restriction does not interfere with our ability to be reimbursed for the products and/or services which we provide to you. You have the right to inspect all medical information we have on file for you by requesting such in writing, at which time we will send you copies, at no charge, of all information we have electronically stored in your name. If you feel that your protected health information has been compromised in any way you have the right to file a complaint, in writing, that we will review and respond to immediately. We take any such complaints very seriously, and complaints regarding protected health information are handled at the very highest levels of the company. You also have the right file such a complaint with the U.S. Department of Health and Human Services (DHHS). 

I have read the above Patient Bill of Rights and Responsibilities and the HIPAA Privacy Notice and fully understand my rights, obligations and protections as governed by law.

MEDICARE DMEPOS SUPPLIER STANDARDS

Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).

  1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
  2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
  3. A supplier must have an authorized individual (whose signature is binding) sign the enrollment application for billing privileges.
  4. A supplier must fill orders from its own inventory, or contract with other companies for the purchase of items necessary to fill orders. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or any other Federal procurement or non-procurement programs.
  5. 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 equipment.
  6. 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.
  7. A supplier must maintain a physical facility on an appropriate site and must maintain a visible sign with posted hours of operation. The location must be accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.
  8. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards.
  9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll-free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited.
  10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.
  11. A supplier is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition see 42 CFR 424.57 (c) (1 1 ).
  12. A supplier is responsible for delivery of and must instruct beneficiaries on the use of Medicare covered items, and maintain proof of delivery and beneficiary instruction.
  13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such.
  14. A supplier must maintain and replace at no charge or repair cost either directly; or through a service contract with another company, any Medicare-covered items it has rented to beneficiaries.
  15. 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.

  1. A supplier must disclose these standards to each beneficiary it supplies a Medicare-covered item.
  2. A supplier must disclose any person having ownership, financial, or control interest in the supplier.
  3. A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.
  4. 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.
  5. 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.
  6. A supplier must agree to furnish CMS any information required by the Medicare statute and regulations.
  7. 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 for those specific products and services (except for certain exempt pharmaceuticals).
  8. All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
  9. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
  10. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
  11. A supplier must meet the surety bond requirements specified in 42 CFR 424.57 (d).
  12. A supplier must obtain oxygen from a state-licensed o”xygen supplier.
  13. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 CFR 424.516(f).
  14. A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers.

30. A supplier-must remain open to the public for a minimum of 30 hours per week except physicians (as defined in section 1848U) (3) of the Act) or physical and occupational therapists or a DMEPOS supplier working with custom made orthotics and prosthetics.

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