Patient acknowledges that Medtech Enterprises will attempt to bill patient’s insurance company and that any monies that is not covered by will be the responsibility of the patient and must be paid to Medtech Enterprises.
Assignment of Insurance Benefits/ Release of Information
I herby authorize payment for medical services and/ or services directly to Medtech Enterprises, LLC. I represent that I have insurance coverage and do hereby authorize Medtech Enterprises, LLC. to release and obtain all information necessary to acquire payment of said benefits. If my insurance fails to pay in full, I agree to pay all unpaid balances. If litigation is instituted to collect any unpaid balances, I agree to also pay all cost, including reasonable attorney’s fees incurred by Medtech Enterprises, LLC. in effort to collect this debt. I have read and agree to the terms and conditions stated above. I also understand that I am responsible for the charges that occur until arrangements have been made for the device to be picked up.
I understand that if I have any questions concerning my device I can call Medtech Enterprises at 800.461.0129. I understand that this device is fully guaranteed under the manufacture warranty normal use for 90 days and that Medtech Enterprises, LLC. will make any repairs to my device, or replace my device as necessary and free of charge, during the warranty period. I understand that this guarantee does not apply to changes that may occur due to any alterations made by anyone other than Medtech Enterprises, LLC. I also understand that if I am not satisfied with the device that I may return the unit in unworn new condition within the first 14 days of dispensing to one of the locations or via mail at my expense. My insurance and any monies that I have paid will be credited back within 30 days. I am satisfied with the fit of my device and I have been fully advised as to its use and function.
Patient Rights:
The patient has the right to considerate and respectful service, The patient has the right to obtain service without regard to race, creed, national origin, sex, age, disability, diagnosis or religious affiliation. 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. The patient has the right to make informed decisions about his/her care. The patient has the right to reasonable continuity of care and service. The patient has the right to voice grievances without fear of termination of service or other reprisal in the service process. If at anytime you feel that your rights were violated please contact Medtech Enterprises at 800.461.0129 or Compliance team at 215.654.9110.
Patient Responsibilities:
The patient should promptly notify the Medtech Enterprises of any equipment failure or damage. The patient is responsible for any equipment that is lost or stolen while in their possession and should promptly notify Home Medical Equipment Company in such instances. The patient should promptly notify the Home Medical Equipment Company of any changes to their address or telephone. The patient should promptly notify the Home Medical Equipment Company of any changes concerning their physician. The patient should notify the Home Medical Equipment Company of discontinuance of use. 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.
SMS/Text Messaging Terms & Conditions:
Medtech Enterprises may contact you by SMS/text messaging regarding your care and account. Messages may include appointment reminders, order status updates and delivery notifications, billing and payment reminders, and important account or service alerts. Messaging frequency may vary depending on your activity. Message and data rates may apply. You may opt out of receiving SMS messages at any time by replying STOP to any message you receive. After opting out, you will no longer receive SMS messages from us, except those required by law. For assistance, reply HELP to any message or contact Medtech Enterprises at 800.461.0129.
As Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)Our organization is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We will let you know promptly if a breach a occurs that may have compromised the privacy or security of your information. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of the notice of privacy practices that we have in effect as of 09/23/2013.
To summarize, this notice provides you with the following important information: How we may use and disclose your identifiable health information, Your privacy rights in your identifiable health information, Our obligations concerning the use and disclosure of your identifiable health information. Please see details on reverse page.
The terms of this notice apply to all records containing your identifiable health information that are created or retained by our practice. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records our practice has created or maintained in the past, and for any of your records we may create or maintain in the future. Our organization will post a copy of our current notice in our offices in a prominent location, and you may request a copy of our most current notice during any office visit.
If you have any questions about this notice please contact Lennie Furr, Medtech Enterprises LLC, 6860 Big Ridge Road Hixson, TN 37343, 800.461.0129
We may use and disclose your information for the purpose of: Treatment. Our organization may use your identifiable health information to treat you. For example, we may perform a follow-up interview and we may use the results to help us modify your treatment plan. Many of the people who work for our organization may use of disclose your identifiable health information in order to treat you or to assist others in your treatment. Additionally, we may disclose your identifiable health information to others who may assist in your care, such as your physician, therapists, spouse, children, or parents. Payment. Our organization may use and disclose your identifiable health information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your identifiable health information to obtain payment from third parties who may be responsible for such costs, such as family members. Also, we may use your identifiable health information to bill you directly for services and items. Health Care Operations. Our organization may use and disclose your identifiable health information to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our organization may use your health information to evaluate the quality of care you received from us or to conduct cost-management and business planning activities for our practice. Appointment Reminders. Our organization may use and disclose your identifiable health information to contact you and remind you of visits/deliveries. Health-Related Benefits and Services. Our organization may use and disclose your identifiable health information to inform you of health-related benefits or services that may be of interest to you. Release of Information to Family/Friends. Our organization may release your identifiable health information to a friend or family member who is helping you pay for your health care of who assists in taking care of you. Disclosures Required By Law. Our organization will use and disclose your identifiable health information when we are required to do so by federal, state, or local law. Special circumstances The following categories describe unique scenarios in which we may use or disclose your identifiable health information: Public Health Risks. Our organization may disclose your identifiable health information to public health authorities who are authorized by law to collect information for the purpose of : Maintaining vital records, such as births and deaths, Reporting child abuse or neglect, Preventing or controlling disease, injury, or disability, Notifying a person regarding potential exposure to a communicable disease, Notifying a person regarding a potential risk for spreading or contracting a disease or condition, Reporting reactions to drugs or problems with products or devices, Notifying individuals if a product or device they may be using has been recalled, Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information, Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance. Health Oversight Activities. Our organization may disclose your identifiable health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general. Lawsuits and Similar Proceedings. Our organization may use and disclose your identifiable health information in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your identifiable health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. Marketing. We will never market or sell your personal information. Law Enforcement. We may release identifiable health information if asked to do so by a law enforcement official: Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement, Concerning a death we believe might have resulted from criminal conduct, Regarding criminal conduct at our offices, In response to a warrant, summons, court order, subpoena, or similar legal process, To identify/locate a suspect, material witness, fugitive, or missing person, In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)
Serious Threats to Health or Safety. Our organization may use and disclose your identifiable health information 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. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. Military. Our organization may disclose your identifiable health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. National Security. Our organization may disclose your identifiable health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your identifiable health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. Inmates. Our organization may disclose your identifiable health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you; (b) for the safety and security of the institution; and/or (c) to protect your health and safety or the health and safety of other individuals. Workers’ Compensation. Our organization may release your identifiable health information for workers’ compensation and similar programs.
Your rights regarding your identifiable health You have the following rights regarding the identifiable health information that we maintain about you: Confidential Communications. You have the right to request that our organization 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. In order to request a type of confidential communication, you must make a written request to Lennie Furr Medtech Enterprises LLC, 2158 Northgate Park LN Suite 408 Chattanooga TN, 37415 800.461.0129 specifying the requested method of contact or the location where you wish to be contacted. Our organization will accommodate reasonable requests. You do not need to give a reason for your request. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your identifiable health information for the treatment, payment, or health care operations. Additionally, you have the right to request that we limit our disclosure of your identifiable health information to 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. If you pay for a service out-of-pocket, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say yes unless a law requires us to share that information. In order to request a restriction in our use of disclosure of your identifiable health information, you must make your request in writing to Lennie Furr Medtech Enterprises LLC, 2158 Northgate Park LN Suite 408 Chattanooga TN, 37415 800.461.0129 address & phone. Your request must describe in a clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our practice’s use, disclosure, or both; and (c) to whom you want the limits to apply. Inspection and Copies. You have the right to inspect and obtain a copy of the identifiable 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 Lennie Furr Medtech Enterprises LLC, 2158 Northgate Park LN Suite 408 Chattanooga TN, 37415 800.461.0129. In order to inspect and/or obtain a copy of your identifiable health information. Our organization may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Reviews will be conducted by another licensed health care professional chosen by us. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing and submitted to Lennie Furr Medtech Enterprises LLC, 2158 Northgate Park LN Suite 408 Chattanooga TN, 37415 800.461.0129 you must provide us with a reason that supports your request for amendment. Our organization will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is: (a) accurate and complete; (b) not part of the identifiable health information kept by or for the organization; (c) not part of the identifiable health information which you would be permitted to inspect and copy; or (d) not created by our organization, unless the individual or entity that created the information is not available to amend the information. Accounting of Disclosures. All of our patients have the right to requests an “accounting of disclosures.” An “accounting of disclosures” is a list of certain disclosures our organization has made of your identifiable health information. In order to obtain an accounting of disclosures, you must submit your request in writing to Lennie Furr Medtech Enterprises LLC, 2158 Northgate Park LN Suite 408 Chattanooga TN, 37415 800.461.0129. All requests for an “accounting of disclosures” must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our organization will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs. Right to Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Lennie Furr Medtech Enterprises LLC, 2158 Northgate Park LN Suite 408 Chattanooga TN, 37415 800.461.0129 Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services. To file a complaint with our organization, Lennie Furr Medtech Enterprises LLC, 2158 Northgate Park LN Suite 408. Chattanooga TN, 37415 800.461.0129 or The compliance Team at 888-291-5353 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 organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your identifiable health information for the reasons described in the authorization. Please note that we are required to retain records of your care.
The products and/or services provided to you by Medtech Orthopedics are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g. honoring warranties and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards.