Please provide the following contact information. At the end of this form please print it, sign it and mail it to The address at the top of the page.
| First Name | Date of Birth | ||
| Last Name | Sex |
Male Female |
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| Middle Initial | Height | ||
| Permanent Address | Weight | ||
| Permanent Address (cont') | |||
| Permanent City | Married | ||
| Permanent State | |||
| Permanent Zip/Postal Code |
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| Permanent Phone | |||
| Local Address | |||
| Local Address (cont') | |||
| Local City | |||
| Local State | |||
| Local Zip/Postal Code | |||
| Local Phone | Medicare Coverage | ||
| FAX | Medicare Number | ||
| Accident Date | |||
| Employment by: | Student | Other | |
| Insurance Information | Insured's Name | ||
| Insurance Company | Policy Number | ||
| Contact Name | Employee Group # | ||
| Address | Po Box | ||
| City | State | ||
| Zip | Phone | ||
| Doctor Information | |||
| Last Name | First Name | ||
| Address | Suite | ||
| City | State | ||
| Zip | Phone | ||
| Diagnosis | Fax | ||
| Care Giver Guardian Next of Kin |
Phone # | ||
| Referral | Phone # | ||
| I authorize any holder of
medical information about me to release to Elite Home Health Care,
Inc. and the Health Care Financing Administration and its agents any
information needed to determine these benefits. I authorize the
release of the information in my file to any governmental agency
such as Medicare, Medicaid, and Joint Commission on Accreditation of
Healthcare Organizations, etc. I the undersigned, by signing hereto,
release Elite Home Medical Supplies from any and all injuries
arising from the equipment received from Elite Home Medical
Supplies.
If covered by Medicare I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. |
|||
| Signature (required after printing) |
|
Date | |
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. An authorized individual (one whose signature is binding) must sign the application for billing privileges.
4. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to
fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care
programs, or from 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.
8. A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these
standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign
and posted hours of operation.
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 or cell phone 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 must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits
suppliers from calling beneficiaries in order to solicit new business.
12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of
delivery.
13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company,
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.
16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
18. 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.
19. 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.
20. 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.
21. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.
22. 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 of those specific products and services (except for certain exempt pharmaceuticals). Implementation Date -
October 1, 2009
23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in
order to bill Medicare.
25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they
are seeking accreditation.
26. Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation date- May 4, 2009
__________________________________________________________________________________________
4/9/2009 Palmetto GBA Page 1 of 1
National Supplier Clearinghouse
P.O. Box 100142 • Columbia, South Carolina • 29202-3142 • (866) 238-9652
A CMS Contracted Intermediary and Carrier
I have received a copy of the Supplier Standards
___________________________________________ __________________________
Signature
Date
Elite Home Medical Supplies
706 West Lumsden Road
(813) 654-2415 (800) 229-9600 Brandon, Fl 33511 www.elitemedical.com
Acknowledgement of Receipt of Notice of Privacy Practices
I certify that I have received a copy of Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and
disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Elite
Home Medical Supplies' health care operations. The Notice of Privacy Practices also describes my rights and Elite Home Medical
Supplies' duties with respect to my protected health information. The Notice of Privacy Practices is posted in on the front counter of
the showroom of Elite Home Medical Supplies and on Elite Home Medical Supplies website at www.elitemedical.com.
Elite Home Medical Supplies reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I
may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, asking for
one at the time of my next visit to their office or accessing Elite Home Medical Supplies website at
www.elitemedical.com.
______________________________________
Signature of Patient or Personal Representative
______________________________________
Name of Patient or Personal Representative
___________________________
Date
___________________________________________________
Description of Personal Representative’s Authority
ELITE HOME MEDICAL SUPPLIES
706 West Lumsden Road Brandon, Florida 33511
(813) 654-2415 (800) 229-9600 FAX (813) 651-9085
www.elitemedical.com
Patient/Client Bill of Rights
1. As an individual receiving home care services, let it be known and understood that you have the following rights:
2. To select those who provide your home care services.
3. To be provided with legitimate identification by any person or persons who enter your residence to provide home care services for
you.
4. To receive the appropriate or prescribed service in a professional manner without discrimination relative to your age, race, sex,
religion, ethnic origin, sexual preference or physical/mental handicap.
5. To be dealt with and treated with friendliness, courtesy and respect by each and every individual representing the company who
provides treatment or services for you and be free from neglect or abuse, be it physical or mental.
6. To assist in the development and planning of your home care program so that it is designed to satisfy, as best as possible to your
current needs.
7. 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.
8. To express concerns or grievances or recommend modifications to your home care service without fear of discrimination or reprisal.
The Medicare hotline number is 1-800-633-4227.
9. To request and receive complete and up-to-date information relative to your condition, treatment, alternative treatments and risks
of treatment.
10. 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.
11. 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.
12. To request and receive the opportunity to examine or review your medical records.
13. I have been given a copy of the Patient/Client Bill of Rights
Patient’s Signature: __________________________Date: _____/_____/_____