PATIENT AGREEMENT AND CONSENT

Request for Products, Equipment, Supplies, Service

The undersigned, being the above-named patient (“Patient”), his/her guardian or representative payee, understands that by signing the Patient Agreement and Consent, the undersigned desires to rent or purchase, as or on behalf of Patient, certain medical equipment, products, supplies and/or associated services from (“Provider”).
Acknowledgement of Medical Responsibility and Informed Consent
The undersigned, understands that (1) Patient is under the supervision and control of his/her attending physician; (2) Patients physician has prescribed the items noted as part of Patient’s treatment; (3) Provider’s services do not include diagnostic, prescriptive or other functions typically performed by licensed physicians; and (4) Patients physician is solely responsible for diagnosing and prescribing the items or other therapies for Patient’s condition and for otherwise controlling Patient’s medical care. The undersigned has been informed of the possible increased risks associated with the care and has been provided the opportunity to discuss his/her concerns with Patient’s physician and has had all associated questions answered to his/her satisfaction.

Acknowledgement of Receipt and Agreement to Contact

The undersigned acknowledges receipt of a copy of each of the following: (1) the Medicare Supplier Standards; (2) Provider’s Notice of Privacy Practices; (3) the Patient’s Bill of Rights; and (4) the Patient Responsibilities (5) Warranty Information of Equipment if Applicable. The undersigned agrees that Provider may contact Patient at the contact information provided.

Consent to Release of Health Information for Treatment, Payment, and Health Care Operations

The undersigned authorizes (1) Patient’s insurer(s) and any other third party payers which provide Patient with coverage to disclose to Provider minimum necessary information to facilitate payment to Provider for items furnished Patient including, but not limited to (A) payment made by such payers to Patient, the undersigned or to any other person or entity for items provided by Provider to Patient; and (B) the scope and extent of Patient’s coverage from time to time; (2) all medical personnel involved in Patient’s treatment to disclose to Provider any and all information concerning Patient’s medical history and condition as it may relate to the items or treatment provided to Patient by Provider; and (3) any holder of medical information about Patient (including Provider) to release to the Centers for Medicare & Medicaid Services and its agents, to other governmental agencies and their agents, to any of Patient’s third party payers, and to Provider, any information needed (subject to “minimum necessary” requirements, as applicable)
(A) to determine applicable benefits and qualification for reimbursement of items furnished by Provider to Patient; (B) to process claims for items furnished by Provider to Patient; and/or (C) to conduct healthcare compliance, activities, accreditation, and/or and quality assurance or utilization reviews. The undersigned hereby authorizes his/her healthcare providers and payers to rely on this “Consent to Release of Health Information” without the need for a separate release authorization, to release the specified information for treatment, payment and health care operations as contemplated herein. This consent shall not be effective to permit disclosures of information in cases where a HIPPA compliant release authorization is required pursuant to 45 CFR § 164.508.

Agreement to Pay

The undersigned agrees to remit payment for all items and/or services provided. Any estimated coinsurance is due at the time of service. The balance due will be that portion of Provider’s applicable charges not paid by insurance or any other payer, including coinsurance, co-payment and deductible amounts, as well as amounts due for non-covered items. The undersigned agrees to pay the balance due in fill upon receipt of an invoice from Provider. If prompt payment is not made, Provider may pursue its standard collection policy or other applicable remedies at Provider’s sole discretion. Under the Providers standard collection policy, all legal fees including attorney and court fees will be the responsibility of the undersigned. The undersigned agrees that an interest of 1 % monthly will be due for all outstanding payment and will be added to the total outstanding amount due. The undersigned agrees that if payor requirements for treatment compliance are not met, the provider may balance bill the patient for equipment, or pick up non-life supporting equipment at the Provider’s discretion.

Assignment of Benefits

The undersigned requests that payment of authorized benefits be made to Provider and authorizes Provider to collect directly all public and private insurance coverage benefits due, for any items furnished to Patient by Provider. In the event benefit payments due Provider are paid directly to Patient or the undersigned, the payee shall immediately and without request from Provider, endorse and remit to Provider all such benefit payment checks. If payment is not remitted in full within 30 days upon receipt from the insurance provider, Provider will pursue its standard collection policy. On assigned Medicare claims, Provider agrees to accept the applicable Medicare allowable amount (including deductibles and co-payments paid by the undersigned) as payment in full for covered items.

Medicare Capped Rental Notification

I received instruction and understand that Medicare may define certain items of durable medical equipment that I received as being either a capped rental or an inexpensive or routinely purchased item. For capped rental items; Medicare will pay a monthly rental fee for a period not to exceed 13 months for PAP therapy and 60 months for oxygen, after which ownership of the equipment is transferred to the Medicare beneficiary. After ownership of the equipment is transferred to the Medicare beneficiary, it will be the beneficiary’s responsibility to arrange for any required equipment service or repair. For inexpensive or routinely purchased items; equipment in this category can be purchased or rented; however; the total amount paid for monthly rentals cannot exceed the fee schedule purchase amount.

Waiver of Clinical Responsibility

SAVVYMED Inc. DBA CPAPforMe is a supplier of respiratory devices and supplies. Your physician has prescribed this equipment and due to the important nature of the proper use of this equipment, it is important that you understand the companies’ responsibility for the use of this equipment in your home. This unit is not a life support device. In the event of a malfunction, you may contact our office at 732-800-6464. When this unit is purchased, you will be responsible for repair/replacement expenses.

Miscellaneous

The undersigned certifies that the information provided to Provider by or on behalf of Patient under Medicare (Title XVIII of the Social Security Act) and/or any other public or private health insurance is correct. Patient, if physically and mentally competent, must sign the Patient Agreement and Consent on his/her own behalf. If patient cannot sign for self, the source of the undersigned’s authority to sign must be stated. This Patient Agreement and Consent is used in lieu of Patient’s signature on the “Request for Payment” HCFA-1500 and on other health insurance claim forms requiring signature and thus, is an extension of those forms. A copy of this Patient Agreement and Consent may be used in place of the original. The undersigned certifies that (1) he/she is the Patient or is duly authorized to execute this Patient Agreement and Consent and to accept its terms as or on behalf of Patient and
(2) he/she has read the foregoing and understand and agrees to the terms hereof as or on behalf of Patient.

PAP Resupply Program

In order to achieve the most comfortable, hygienic and effective sleep therapy possible it is important to replace your mask and supplies on a regular basis. Your mask, tubing, filters and other supplies are affected by use, oils from your skin and cleaning. Even with regular maintenance they may deteriorate, crack, or begin to promote bacteria growth. As part of our ongoing effort to provide the best level of service, medically necessary supplies will be shipped direct to you; no shipping or handling fees. Medicare and other health insurers suggest the replacement of such supplies according to the following replacement schedule:
 1 Mask Every 3 Months
 1 Headgear Every 6 Months
 Chin Strap Every 6 Months
 Cushions/ Nasal Pillows Every 1 Month
 Tubing Every 3 Months
 Disposable filters Every 1 Month
 1 Non- Disposable filet every 6 Months
 1 Humidifier Water chamber every 6 Months
You will be enrolled in our PAP resupply program unless you choose not to. We look forward to making sure you receive the supplies necessary to remain compliant while on PAP therapy.

Freedom Of Choice

You are free to obtain your prescribed medical equipment and accessories from any supplier that you choose. A listing of alternative suppliers can be found by contacting your insurance company, looking online, or other appropriate listing directory. Your choice of supplier will never, under any circumstances affect how you will be treated by us. In addition, the medical equipment and supplies associated with the referral may be considered to be, and may be reimbursed at an “out-of-network” level by your insurance carrier or other third party payer. You should inquire about out-of-network billing for your medical equipment and supplies by contact our office directly at 732-800-6464.

Medicare DMEPOS Supplier Standards

The products and/or services provided to you by (supplier legal business name or DBA) 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.

SERVICE REPAIR AND RETURN POLICY

SAVVYMED Inc. DBA CPAPforMe will accept returns for any items that are deemed to be defective, substandard or inappropriate for the indicated use. Our return policy is as follows:
Rental Equipment: Equipment actively being rented from SAVVYMED Inc. DBA CPAPforMe may be returned at any time for any reason. In some instances, rental equipment that has been ordered by a physician and is being returned without physician approval may require us to inform your physician of the discontinuation of service. Rental items returned in the middle of a month’s rental will not be pro- rated, the entire months rental charge will still apply.
Purchased Equipment: Equipment that is purchased outright may be returned within 30 days if the equipment is found to be defective, substandard or inappropriate for the indicated use. For any defects or deficiencies occurring after the 30 days our service and repair policy will be in effect.
Supplies and consumables: Supplies and consumables provided may be returned within 10 days of the date delivery if deemed to be inappropriate or unnecessary. Defective or incorrect supplies may be exchanged within 30 days of the date of delivery. All supplies being returned or exchanged must be in the original sealed packaging. Used items will not be accepted for return or refund.
SAVVYMED Inc. DBA CPAPforMe will repair, replace or service any items that we provide according to the manufacturer’s warranty and insurance guidelines.