1- By signing this agreement I confirm that received the following form Caring Med:
- a- Client Handbook which includes the following: Caring Med mission and vision statement, Client’s rights and responsibly, Normal business hours and contact information, Terms and Conditions, Caring Med Privacy Policy, HIPAA Privacy Notice, MEDICARE DMEPOS SUPPLIER STANDARDS.
- b- Warranty. I received a warranty note and I am aware of how to keep the warranty valid.
- c- Usage. I received the manufacturer’s operating and/or user manual, and I am aware how to operate/use the device (s) provided in proper and safe way.
2- I received an orientation on how to operate/use the device (s) provided in proper and safe way.
3- I understand that by signing this agreement, I authorize provision of products and/or services to me by Caring Med. I also understand that the products and services provided are prescribed by my physician OR I requested it and that It is necessary that I remain under the supervision of my attending physician during the course of my care.
4- Same or Similar Equipment. I understand that my insurance carrier may not cover the above named equipment and I may be asked to execute an Advance Beneficiary Notice.
5- Release of Information. I hereby authorize release to Caring Med any and all of my medical records pertaining to my medical history, services rendered, or treatments received from my physician(s) or hospital. In order to process insurance claims, I also hereby authorize Caring Med to furnish to my insurance carrier(s), any medical history, Services rendered, or treatment needed.
6- Assignment of Benefits. I authorize direct payment of insurance benefits by my insurance company to Caring Med. In the event that my insurance carrier does not accept “assignment of benefits”, I understand that payments may be sent directly to me and that I am obligated to endorse and directly send such payments to Caring Med for payment of my bill.
7- Financial Responsibility. I understand that I am responsible to Caring Med for all charges not covered by my insurance. I recognize that in the event that my insurance company, employer, or any other third party payer refuses to pay purchase price(s) of the above items, or delays payment beyond 90 days of my receipt of items, or in the event that I have no insurance coverage or third party payer, that I will be responsible for said payments and will make prompt reimbursement within 30 days of notification by Caring Med for all charges.