LTC PROVIDERS, INC DME Instruction Delivery

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1 Name: Address: Phone: OTHER HOME CARE SERVICES: Discuss all appropriate factors and if in order SAFETY Uncluttered pathways Fire safety assessed Safe operating equip Cords & Adapters Safe environment Pt/CG understands safety issues Bathroom assessed Safe electrical outlet Area Rugs Getting in & out of device Other: LTC PROVIDERS, INC DME Instruction Delivery Date of Visit Initial Delivery Follow-up Phone: HOME ENVIRONMENT/SAFETY APPROPRIATE FOR HOME-GENERAL DME Yes No Alert & Understands operation of equipment Confused/ caregiver instructed Personal/Physical limit EQUIPMENT & SERIAL NUMBER IF APPLICABLE Manual Wheelchair Power Wheelchair Hospital beds Patient Lifts Support Surfaces Ambulatory Aids CPAP & Supplies Nebulizer Commodes Scooters Pain Management Oxygen Other Equipment As a representative of LTC Providers, I have reviewed and assessed this home environment and agree with the patient that they can safely maneuver this mobility device (POV/Power wheelchair, manual wheelchair, walker, cane), in their home. LTC Providers Representative s Signature Date Patient s Signature Date ADDITIONAL INSTRUCTIONS & DOCUMENTS PROVIDED I, the Patient/Caregive, certify; I have been educated, instructed and provided the following checked documentation listed below Patient s Rights & Responsibilities Cleaning & Maintenance of equipment infectious control Medicare & LTC Providers Standards Consent to Privacy Practices Complaint process Notification of Information Practices Advance Directive (if applicable) Authorization of Assignment of benefits Warranty/Repair instructions FOLLOW UP/DISCHARGE FOLLOW-UP VISIT RECOMMENDED FOLLOW-UP BY PHONE & AS NEEDED Patient s Signature Date If patient is unable to sign, Print Name & relationship to this patient above LTC Providers Representative Signature Date Authorized Person s Signature Date Copyright The Compliance Team, Inc. ALL RIGHTS RESERVED Updated

2 Medicare Capped Rental Service and Inexpensive or Routinely Purchased Item Notification for Services on or after January 1, 2006 I received instructions and understand that Medicare defines the items that I received as either a capped rental service or an inexpensive or routinely purchased item. FOR CAPPED RENTAL ITEMS: Medicare will pay a monthly fee for a period not to exceed 13/36 months, after which ownership of the equipment is transferred to the Medicare beneficiary. After ownership of the equipment is transferred to the Medicare beneficiary, it is the beneficiary s responsibility to arrange for any required equipment service or repair. Examples of this type of equipment include: Hospital beds, wheelchairs, alternating pressure pads, air-fluidized beds, nebulizers, suction pumps, continuous airway pressure (CPAP) devices, patient lifts, and trapeze bars. FOR INEXPENSIVE OR ROUTINELY PURCHASED ITEMS: Equipment in this category can be purchased or rented; however, the total amount paid for monthly rentals cannot exceed the fee schedule purchase amount. Examples of this type of equipment include: Canes, walkers, crutches, commode chairs, low pressure and positioning equalization pads, home blood glucose monitors, seat lift mechanisms, pneumatic compressors (lymphedema pumps), bed side rails and traction equipment. Product Capped Inexpensive/Routinely Purchase Rental Initial Service Purchased Item Option Option Beneficiary Signature Date

3 Copyright The Compliance Team Inc. All rights reserved. Notification of Information Practices LTC Providers Inc. The purpose of the consent form is to inform you, the patient, how your personal health information is used and/or disclosed by this provider or organization. We want you to be fully aware of what we do with your information so that you can provide us with your consent in order for us to treat your health care needs, receive payment for services rendered, and allow administrative and other types of health care operations to happen, which are part of normal business activities of the provider or organization. Your consent I understand that as part of my health care, this organization originates and maintains health records describing my health history, symptoms, test results, diagnoses, treatment, and plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment. A means of communication among my diagnosis/es and other health information to my bill(s). A source of information for applying my diagnosis/es and other health information to my bill(s). A means by which my health plan or health insurance company can verify that services billed were actually provided. A tool for routine health care operations in this organization, such as ensuring that we have quality processes and programs in place and making sure that the professionals who provide your care and competent to do so. I understand that: I have been provided with a Notice of Information Practices that provides specific examples and descriptions of how my personal health information is used and discloses by LTC Providers, Inc.; I have the right to review the Notice of Information Practices prior to signing this consent; LTC Providers, Inc can change its Notice of Information Practices but notify me of those changes before they are put into practice and will mail me a copy of the new Notice to the address that I have provided; I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations and that LTC Providers, Inc. is not required to agree to those restrictions; Any restrictions to which LTC Providers, Inc. agrees to will be respected. I may revoke this consent in writing at any time. Further, I am aware that LTC Providers, Inc. can proceed with uses and disclosures that pertain to treatment, payment, or healthcare issues that took place before the consent was revoked. To request a restriction on the use and disclose of your personal health information related to your treatment, payment for service, or for the health care operations of LTC Providers, Inc., please do so after reading the Notice of Information Practices. You may use this consent form to request a restriction. I request the following restrictions to the use or disclosure of my health information. Patients signature Date Your signature is required if restrictions have been requested. Please mail this signed restriction request to: LTC Providers, Inc, PO Box 69, Attention: Privacy Restrictions, Sullivan, MO Copyright The Compliance Team Inc. All rights reserved.

4 LTC PROVIDERS REPAIR POLICY FOR PATIENT OWNED EQUIPMENT Updated LTC SERVICE POLICY WITHIN THE FIRST 90 DAYS NO SERVICE OR LABOR CHARGES ON TRAINING, WHEELCHAIR ADJUSTMENTS AND PRODUCTS COVERED UNDER WARRANTY. NOT COVERED UNDER WARRANTY: EXAMPLES: DAMAGE OR SERVICES NEEDED FROM UTILIZATION OF THE EQUIPMENT OUTSIDE OF ITS INTENDED USE OR IMPROPER MAINTENANCE. $75 UP FRONT DIAGNOSTIC FEE (DIAGNOSTIC FEE CAN BE WAIVED IF BROUGHT TO AN LTC SERVICE CENTER) ALL PARTS AND LABOR CHARGES TO BE BILLED TO PATIENT OR THEIR INSURANCE UNLESS COVERED UNDER WARRANTY AFTER THE FIRST 90 DAYS $75.00 UP FRONT DIAGNOSTIC SERVICE CALL DIAGNOSTIC FEE CAN BE WAIVED IF BROUGHT TO AN LTC SERVICE CENTER ALL PARTS AND LABOR CHARGES TO BE BILLED TO PATIENT OR THEIR INSURANCE UNLESS COVERED UNDER WARRANTY LABOR RATE = $75.00/HOUR MEDICARE RENTALS AVAILABLE FOR GROUP 2 CAPTAIN STYLE POWER CHAIRS (LIABILITY REASONS EXCLUDE RENTALS FOR CUSTOM SEATING SYSTEMS) IF PARTS ARE NOT COVERED UNDER WARRANTY OR INSURANCE COVERAGE IS UNCERTAIN, PAYMENT PRIOR TO ORDERING THE PARTS IS REQUIRED. MASTERCARD, VISA, AMERICAN EXPRESS, DISCOVER, MONEY ORDERS, PERSONAL CHECKS, AND CASH ARE ACCEPTED METHODS OF PAYMENT

5 LTC PROVIDERS INC Patient Rights & Responsibilities Consent to Privacy Practices Patient Rights: 1. The patient has the right to considerate and respectful service. 2. The patient has the right to obtain service without regard to race, creed, national origin, sex, age, disability, diagnosis or religious affiliation. 3. Subject to applicable law, the patient has the right to confidentiality of all information pertaining to his/her medical equipment service. Individuals or organizations not involved in the patient s care, may not have access to the information without the patient s written consent. 4. The patient has the right to make informed decisions about his/her care. 5. The patient has the right to reasonable continuity of care and service. 6. The patient has the right to voice grievances without fear of termination of service or other reprisal I n the service process. Patient Responsibilities: 1. The patient should promptly notify LTC Providers, Inc of any equipment failure to change. 2. The patient is responsible for any equipment that is lost or stolen while in their possession and should promptly notify LTC Providers, Inc in such instances. 3. The patient should promptly notify LTC Providers, Inc of any changes to their address or telephone. 4. The patient should promptly notify LTC Providers, Inc of any changes concerning their physician. 5. The patient should notify LTC Providers Inc of discontinuance of use. 6. Except where contrary to federal or state law, the patient is responsible for any equipment rental and sale charges which the patient s insurance company/companies does not pay. Consent to Privacy Practices of LTC PROVIDERS INC. Inc. Effective Date: April 14, 2003 You have been provided with a copy of LTC PROVIDERS INC. Notice of Privacy Practices that describes how we will use health information concerning our service to you. The notice details how we will use this information to provide treatment care for you, to gain reimbursement for our services and to improve our operations to better serve you and other patients. We are required to document that: We have given you our Notice of Privacy Practices and that you have had the opportunity to review it; LTC PROVIDERS INC. will notify you of changes in our Notice of Privacy Practices prior to implementing those changes; You may request restrictions as to how your health information may be used although LTC PROVIDERS INC. is not required to agree to those restrictions; Any restrictions to which LTC PROVIDERS INC. agrees to will be respected. You may revoke this consent in writing at any time, although LTC PROVIDERS INC. can proceed with uses and disclosures that pertain to treatment, payment, or healthcare issues that take place before the consent was revoked..

6 Patient/Customer Complaint To process a complaint or an unresolved issue, please call during normal business hours. Phone number or Monday through Friday 8:00 AM to 5:00 PM Please request to speak with the Customer Service Manager. Or You may send a written complaint to: LTC Providers, Inc PO Box 69 Attention: Complaint Department Sullivan, MO Grievance Procedure We believe that a client who understands and participates in their care may achieve better results. You have the right to freely voice grievances and recommend changes in care or services without fear of reprisal or unreasonable interruption of services. We are here to assist you with any problems which may occur and agree to work with you to resolve your complaint in timely fashion. Every attempt will be made to resolve the complaint to the satisfaction of those involved and is reasonably allowed.