Welcome Packet

WELCOME TO HYGEIA

Hygeia Medical Supplies provides compliant, patient-centered durable medical equipment and medical supply services that promote patient safety, independence, and quality of life. We are committed to delivering reliable service while maintaining full compliance with applicable federal, state, and accreditation requirements.

Patient/Client Bill of Rights

As an individual receiving home care services, let it be known and understood that you have the following rights:

To select those who provide your home care services.
To be provided with legitimate identification by any person or persons who enter your residence to provide home care services for you.
To receive the appropriate or prescribed service professionally without discrimination relative to your age, race, sex, religion, ethnic origin, sexual preference, or physical/mental handicap.
To be dealt with and treated with friendliness, courtesy, and respect by every individual representing the company who provides treatment or services for you and be free from neglect or abuse, be it physical or mental.
To assist in the development and planning of your home care program so that it is designed to satisfy, as best as possible your current needs.
To be provided with adequate information from which you can give your informed consent for the commencement of service, the continuation of service, the transfer of service to another home care provider, or the termination of service.
To express concerns or grievances or recommend modifications to your home care service without fear of discrimination or reprisal. Please contact us at ________________. You can also contact our accreditation organization, HQAA at 866-909-4722. The Medicare hotline number is 1-800-213-5452.
To request and receive complete and up-to-date information relative to your condition, treatment, alternative treatments, and risks of treatment.
To receive treatment and services within the scope of your home care plan, promptly and professionally, while being fully informed as to company policies, procedures, and charges.
To refuse treatment and services within the boundaries set by law, and to receive professional information relative to the ramifications or consequences that will or may result due to such refusal.
To request and receive the opportunity to examine or review your medical records.

Beneficiary Agreement

I agree that I am personally and solely responsible for the payment of charges related to the above-described transactions.

Further, I acknowledge that it is my responsibility to obtain or provide necessary forms and documentation, including physician prescriptions, as may be required to support and document all third-party claims.

Rental Agreement

If this is a Delivery Invoice for the rental of equipment (as indicated on the Transaction Ticket), the following terms apply:

The patient acknowledges receipt of the equipment described on the front side and agrees that the title to the equipment shall be with Company and that this is a transaction for lease only. The patient agrees to protect the equipment from all loss and damages, and remain responsible for it, to release the equipment for pick-up only to a duly authorized representative of the Company, to operate the equipment only in the manner for which it was intended, to refrain from making repairs to the equipment, to notify Company in the event repairs are necessary and to not remove the equipment from the place to which it was delivered without Company's consent and notification.

If the Patient changes physicians or insurance or is admitted into a HOSPITAL or NURSING FACILITY, the Patient will notify Company immediately. Most carriers will not reimburse charges incurred when the beneficiary is in a nursing home, or hospital. If I choose to retain such rented equipment and/or purchase supplies during such periods, I agree that I am solely responsible for payment of any such charges related to such transactions and that no claim will be filed to the carrier by the supplier or myself.

The patient agrees to promptly pay the stated rental each month (without pro-rate) for use of equipment, it is understood that Company will credit the Patient's account for payments received by the Company from any medical insurance program or any third party, provided however if Company accepts assignments from Patient for purposes of receiving insurance reimbursement directly, Patient agrees to promptly pay all appropriate deductible and co-insurance amounts in connection with use of the equipment.

The patient is hereby notified that any equipment/supplies for which a claim or invoice has been processed, filed, and/or paid is returnable only at the discretion of the Company and in extraordinary circumstances.

Sales Agreement

If this is a Delivery Invoice for a sale of equipment and/or supplies (as indicated on the Transaction Ticket), the following terms apply:

The patient acknowledges receipt of the equipment/supplies described on the front side. The patient agrees to promptly pay the stated price for the equipment/supplies, it is understood that credit will be given to the Patient's account for payments received from any medical insurance program, or from a third party, provided, however, if the Company accepts assignment for the Patient for purposes of receiving insurance reimbursement directly, the Patient agrees to promptly pay all appropriate deductible and co-insurance amounts.

Title to such equipment shall not be transferred from Company until Company receives the total price as indicated on the front side. The Patient is hereby notified that no purchase of equipment for which a claim or bill has been processed, filed, or paid will be accepted for return unless at the discretion of management and in extraordinary circumstances.

Returns

Returns of purchased items will be accepted in unopened packages and/or saleable condition within 30 days from the date of the original invoice, with proof of purchase. There may be a re-stocking fee for returned items. The following will not be accepted for return: merchandise worn next to skin, used for sanitary or hygienic purposes, or disposables e.g., (oxygen, supplies, underpads or diapers, lancets, creams, etc.) Special order items may require a deposit and are non-returnable.

Disclaimer of warranties/use of equipment and supplies

The patient has been informed and agrees that Company is not a manufacturer of the equipment, and therefore makes no warranties, expressed or implied, concerning the equipment/supplies delivered hereunder. All danger, risk, and economic loss associated with the purpose and use of the equipment/supplies delivered hereunder are expressly assumed by the Patient who does hereby release and discharge Company from any claims arising therefrom.

The patient agrees to indemnify and hold the Company harmless from and against any claims, whatsoever, which may be brought by any person whomsoever, arising from the rental, delivery, or use of said equipment. This equipment should be used according to your physician's prescription and in accordance with the manufacturer specifications that may restrict or prohibit the operation or use of the equipment/supplies without further training.

We will honor all warranties expressed or implied under applicable state law and will not charge the beneficiary or the Medicare program for repair or replacement of any Medicare covered items covered under warranty. The company will accept returns for any substandard items, unsuitable, or inappropriate items from Medicare beneficiaries and replace them at no cost.

Complaint Process

We desire to provide you with the best possible service. If you find our service not meeting your expectations, please contact us at _______________________. We will begin an investigation into the complaint and respond to you within 14 days, if you are on Medicare, we are required to respond to you in writing within 14 days of the complaint.

Medicare DMEPOS Supplier Standards

Hygeia Medical Supplies

Acknowledgement of Receipt

(This form is proof that the required information was received by the patient. There is no need to have every page signed or to keep all the above information in the patient packet.)

The following Information has been provided to _____________________________.

- Welcome Packet

- Verbal and Written Instruction

- Return Demonstration

- Medicare Supplier Standards

- Patient Rights and Responsibilities

- Privacy Practice Standards

- Cost of Equipment Supplies Provided

- Hours of Operation

- Complaint Process

- Telephone Number and how to obtain Service

- Warranty Information

- Medicare Capped Rental and Inexpensive or Routinely Purchased Items Notification

By my signature below, I attest that I have received the above-listed instruction and documentation. I will contact Organization Name with any questions regarding the service I have received.

Patient Signature: __________________________________ Date :__________

If someone other than the patient has signed the records, their name and reason the patient was not able to provide a signature:

Name:_________________________________________ Relationship:_____________________

Reason patient was unable to sign: _________________________________________________