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American Homecare Specialists Assignment of Benefits form (printable version)

Medicare Supplier Standards

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 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 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 suppliers 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 any information required by the Medicare statute and implementing regulations.
    Note: If you do not know which Regional Carrier to call, please ask your supplier where your claims are billed.

RIGHTS, RESPONSIBILITIES, RENTAL AND SALES AGREEMENT

AMERICAN HOME CARE SPECIALISTS, INC.
2M GILL ST
WOBURN, MA 01801
1-800-870-2607

COMPANY when used in this agreement, refers to American Home Care Specialists. Patients refer to the person receiving medical supplies and equipment. TITLE to the rental equipment & all parts shall remain with the COMPANY, unless equipment is purchased & paid in full. Patient must promptly notify COMPANY of rental equipment malfunctions or defects, allow COMPANY representatives to enter their premises to perform REPAIR & SERVICE. COMPANY shall not insure or be responsible to patient or caregiver for any  PERSONAL INJURY OR PROPERTY DAMAGE related to any equipment, including that caused by use of improper functioning of equipment, the act or omission of any third party, or by any criminal act or activity, for or act of God. COMPANY retains the right to impose a monthly service charge of 1.5% of the unpaid balance. Sales RETURNS may be accepted in unopened packages & or salable condition within three (3) days from the date of original invoice with proof of purchase. No merchandise may be accepted for return if worn next to the skin, used for sanitary or hygienic purposes or if it is disposable (oxygen, supplies, underpads or diapers, lancets, creams, etc.) Special order items will require a deposit & are non refundable. COMPANY maintains 24-hour availability by telephone. Patient is responsible for monitoring oxygen supply. Patient has the right to PAIN MANAGEMENT. The COMPANY will take steps to obtain PAIN MANAGEMENT by forwarding the information of PATIENT'S PAIN to the physician to facilitate PAIN MANAGEMENT by the physician or another agency. Should a life threatening MEDICAL EMERGENCY arise it is suggested the patient or caregiver contact their local emergency services number for assistance. Patient will be communicated within a way they can understand. Those wishing to express their concerns or comments should contact the COMPANY during regular business hours. Your comments will be reviewed & REFUSAL of any service ordered, delivered to the patient by a health care professional. Patient may participate in all decisions regarding service & will receive experimental treatment only with a voluntary informed consent. Patient personal information will be kept CONFIDENTIAL by the COMPANY. In the interest of health & safety, COMPANY retains the RIGHT TO REFUSE DELIVERY of service at any time. Patient must NOTIFY COMPANY of any MEDICAL STATUS change such as doctor's prescription, hospitalization, acquiring an infectious disease or change in residence. Final benefits of referrals made by COMPANY will be disclosed to the patient. Patient agrees to notify COMPANY of ADVANCED DIRECTIVES (living wills, DNR, etc.) being in place & any changes thereof. Patient and COMPANY agree to go to arbitration if a disagreement arises between the parties.

MISSION STATEMENT - We are a private, for profit Massachusetts corporation with over a century of healthcare experience among leadership & staff in serving residents of the New England area since 1993. We constantly strive to provide the greatest selection and value in home healthcare products, supplies and services to assist in improving the quality of life of our patients.

EXTENDED PATIENT SIGNATURE AUTHORIZATION

TO BE COMPLETED BY COMPANY STAFF - PLEASE PRINT OR TYPE

Beneficiary Name:

Beneficiary Medicare #:

Secondary Insurance #:

Equipment Supplied by American Home Care Specialists, Inc.:

TO BE COMPLETED BY BENEFICIARY OR AGENT - Directions For Payments of Benefits and Release of Medical Information

Statement for payment of Medicare Benefits:

I request that payment of authorized Medicare benefits be made either to me or on my behalf to American Home Care Specialists for any services or items furnished to me by American Home Care Specialists. I authorize any holder of medical information about me to release to Centers for Medicare and Medicaid Services, its agents, accrediting bodies (JCAHO) and any regulatory bodies (FDA) any information needed to determine these benefits or the benefits payable for related services. I understand that I am fully responsible for any deductibles, coinsurance & disallowables unpaid from the Medicare Allowable Rate. Also, I understand that Medicare will only pay for services that it determines as "reasonable and necessary" under section 1862(a) (1) of Medicare law. If determined that a particular item or services, although it would be otherwise covered, is "not reasonable & necessary" under Medicare standards, Medicare will deny payment. We believe that, in your case, Medicare or another carrier is likely to deny payment for the following reasons:

Statement for payment of Medigap (secondary benefits):

I request that payment of authorized MEDIGAP benefits be made either to me or on my behalf to American Home Care Specialists for any services furnished to me by American Home Care Specialists. I authorize any holder of medical information about me to release to (name of MEDIGAP insurer)

____________________________ any information needed to determine these benefits or the benefits payable for related services.

Address of Person signing for Beneficiary:

Relationship of person signing for the Beneficiary:

Reason Beneficiary is unable to sign:

IMPORTANT INFORMATION FOR PHYSICIANS

In submitting claims under this procedure, PHYSICIANS undertake:

1. To complete and submit promptly the appropriate Medicare billing form for all services covered by the request for payment even those in which the physician has not accepted assignment.
2. To incorporate, by stamp or otherwise, information to the following effect on any bills they send to Medicare patients: "DO NOT USE THIS BILL FOR CLAIMING MEDICARE BENEFITS. A CLAIM HAS BEEN OR WILL BE SUBMITTED TO MEDICARE ON YOUR BEHALF". This requirement is necessary to prevent patients from submitting duplicate claims.
3. To cancel the authorization on request by the patient.
4. To make the patient signature files available for carrier inspection upon request.

IMPORTANT INFORMATION FOR SUPPLIERS

1. Only use this extended patient signature authorization for assigned claims.
2. Renew the patient signature agreement if a new item is rented or purchased.
3. Place alongside the beneficiary's signature the following statement: "RESPONSIBLE FOR OVERPAYMENT ON ASSIGNED CLAIMS ACCEPTED"

DURABLE MEDICAL EQUIPMENT SUPPLIERS AGREEMENT

NOTE: THE FOLLOWING STATEMENT MUST BE SIGNED BY THE DME SUPPLIER PRIOR TO AUTHORIZATION OF PAYMENT FOR RENTAL OF DURABLE MEDICAL EQUIPMENT IN ASSIGNMENT CASES.

This supplier assumes unconditional responsibility for refunding of all overpayments for assigned claims for rental of durable medical equipment that may result from the failure of the Carrier to receive prompt notice of the return of, or the end of need for the rental equipment, or the death or institutionalization of the Beneficiary.

INSTRUCTIONS TO CUSTOMER/RETURN DEMONSTRATION & ACKNOWLEDGEMENT

I acknowledge receiving instructions & have demonstrated & or verbalized my understanding in the proper use & care of the equipment & or suppliers listed on the delivery ticket. I have had my financial responsibilities explained to me. I have not rented the equipment on the delivery ticket through Medicare in the past & agree to this entire agreement.

Address of Person signing for Beneficiary:

Relationship of person signing for Beneficiary:

Reason Beneficiary is unable to sign: