Patient Authorization Form

AUTHORIZATION and AGREEMENT FOR SERVICES

HOME HEALTH CARE

If my insurance is a Medicare Plan, I understand that these supplies are NOT covered if I am receiving any kind of Home Health Services. These supplies must be provided by my Home Health Service Provider. If I choose to accept them while under a Home Health Episode, as defined by CMS, I may be financially responsible for the cost of these items.

AUTHORIZATION FOR SERVICES

I authorize PRISM MEDICAL PRODUCTS, LLC to provide supplies and/or services as ordered by my physician. I understand that I have the right to make decisions concerning my medical care, including the right to accept or refuse medical or surgical treatment or medical supplies.

ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITY

I authorize payment directly to PRISM MEDICAL PRODUCTS, LLC of any benefits otherwise payable to examination or treatment of client. I agree to pay any charges not covered by insurance benefit plans, excluding clients with a co-insurance and where payment is prohibited by law. Client is responsible for co-insurance amount of approved charges and any unpaid annual deductibles.  I understand that Medicare or my primary insurance will only cover for products it deems “medically necessary” and payments made by Medicare is based on their regulations, utilization limits and fee schedules. Furthermore, Prism Medical Products, LLC, an entity accredited by The Joint Commission, strives to exceed standards set forth by Medicare and Medicaid.  As a result we believe you have the right to be greater informed of your financial responsibility with our organization.  Should you have any additional questions regarding your financial responsibility with our organization, please contact our billing department prior to use of the enclosed products.  You may find more information regarding your financial responsibility through The Centers for Medicare and Medicaid Services, in their “Medicare Coverage of Durable Medical Equipment and Other Devices, Official Government Booklet” at http://www.medicare.gov/Pubs/pdf/11045.pdf.

SUPPLIER STANDARDS & NOTICE OF PRIVACY PRACTICES

My signature below acknowledges that I have received a copy of the CMS (Medicare) DMEPOS  Supplier Standards and a Notice of Privacy Practices. The Notice of Privacy Practices may also be found at www.prism-medical.com.

RIGHTS AND RESPONSIBILITIES

My signature below acknowledges that I have been notified of the statement of rights and responsibilities and that this information may be found at www.prism-medical.com. You may also call to request the policy via mail.

EMERGENCY MANAGEMENT PLAN

My signature below acknowledges that I have established and understand the emergency plan. I have received PRISM MEDICAL PRODUCTS, LLC’s brochure; I am informed of the nature and procedure to request additional supplies I may need; and I have participated in the planning of my care. There are no home visits appropriate for the care provided. The Prism Emergency Management Plan is located at www.prism-medical.com.You may also call to request the policy via mail.

RELEASE OF INFORMATION

I certify that the information given by me in applying for payment under Title XVIII of the Social Act, or under a policy of insurance is correct. I authorize the home care company or any other holder of medical or other information about the above named client, to release or receive such information to any government agency or insurance company to whom application has been made for payment for services rendered to the above client; to any physicians, hospitals, other healthcare providers or facilities, institutions, or agencies providing treatment to the client or providing continuity of care; and to quality reviewers.

PRODUCT WARRANTY

All supplies distributed by Prism Medical Products, L.L.C. are guaranteed to be free from any defect. Any beneficiary that reports a defective product may return it within 10 business days to be replaced, free of charge. In addition, where applicable, directions for use and warranty information will be provided to beneficiaries for all products provided.  Any remaining sealed supplies may be returned within 30 days for credit to the account. I have been instructed and understand the warranty coverage on the product(s) I have received.

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