Durable Medical Equipment (DME) Form

Durable Medical Equipment (DME) Form
You are being given the following forms which are required in order for you to receive your equipment. Scroll down to the bottom of the page to sign that you have agreed to the forms.

Your DME Supplier and clinic is Kunj Govind Patel MD LLC, a series LLC, with clinic name DBA Center for Regenerative and Interventional Spine and Sports Pain (CRISSP). For the purposes of the remainder of the document, these two names will be used interchangeably to refer to the same DME Supplier.
Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Supplier Standards
Below is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain billing privileges.
PATIENTS' RIGHTS AND RESPONSIBILITIES
PATIENTS' RIGHTS
PATIENTS' RESPONSIBILITIES
PROTOCOL FOR RESOLVING COMPLAINTS FROM MEDICARE BENEFICIARIES
PLAN OF CARE
Initials of the patient or person authorized to sign for patient:*

Clear
Signature
Initials of the patient or person authorized to sign for patient
ADVANCE BENEFICIARY NOTICE (ABN)

NOTE: If Medicare, Medicaid, or your third-party private health insurance does not pay for the item, you may have to pay. Medicare, Medicaid, or your third-party private health insurance does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare, Medicaid, or your third-party private health insurance may not pay for:

	ITEMS
1.
2.
3.
4.
5.

Choose an option below about whether to receive the item listed above:

I want the items listed above. You may ask to be paid now, but I also want Medicare, Medicaid, or my third-party private health insurance billed for an official decision on payment, which is sent to me on an EOB Summary Notice. I understand that Medicare, Medicaid, or my third-party private health insurance does pay, you will refund any payments I made to you, less co-pays, or deductiblesI want the items listed above, but do not bill Medicare, Medicaid, or my third-party private health insurance. You may ask to be paid now as I am responsible for the payment. I cannot appeal if Medicare, Medicaid, or my third-party private health insurance is not billed.I do not want the items listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if my insurance will pay.
This ABN Notice gives our opinion, not official decision whether your health insurance will pay or not. If you have other questions regarding this notice or other areas of your health insurance billing. Please contact your health insurance company directly. For Medicare: 1-800-633-4227. For Medicaid and/or your 3rd party private health insurance company, we are happy to assist with providing you with their contact phone number. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes to response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Signature*
Initials of the patient or person authorized to sign for patient
DELIVERY/ PICK-UP CONFIRMATION
Delivery Pick-up
Date of service:
Delivery Method:
Contact Number:
If you choose Delivery, please enter delivery address below:

Street Address

Street Address Line 2

CityState

Zip CodeCountry
For the clinic ONLY
Same or Similar Information

Medicare, Medicaid, or any other third-party insurance does not pay for same or similar equipment of an item that is already being used. Same or similar denials occur when the patient’s history indicates that an older piece of equipment is of same or similar item to a more recent item being billed that is within the same category. If the beneficiary has had a same or similar piece of equipment within the previous five years, a claim denial referencing the same or similar clause may be expected.
Have you received same or similar DME equipment in the past 5 years?*

YesNo
If yes, who was the provider?

Full NameContact Number
Date of Delivery:
In signing below, you are certifying that the services/equipment was ordered by your physician, and is with your consent, and is delivered to you by this provider.*

Clear
Are you the patient?*

YesNo
If you are signing for the patient, please answer the following:

I am permitted to sign for the patient as I am their legal guardian/medical power of attorney/decision maker.
My name is First Name Last Name, and my relationship to the patient is .
blank
PATIENT DISCLOSURE FORM
Please place a check to confirm that the items listed below have been given and disclosed to you:*

Medicare Supplier StandardsPatient Rights & ResponsibilitiesComplaint ProcessPlan of CareAdvanced Beneficiary NoticeProof of DeliverySignature Agreement form: Consent to Release, Assignment of Benefits, Same or Similar & Non-CoverageWarranty Letter (Found in user manual)Product Instruction/Return demonstrationService availability (hours of operation & contact info)Privacy standards (HIPPA)
SIGNATURE AGREEMENT FOR CONSENT TO RELEASE, ASSIGNMENT OF BENEFITS, SAME OR SIMILAR AND NON-COVERAGE
Please sign below to accept the above policies:*

Clear
Are you the patient?*

YesNo
If you are signing for the patient, please answer the following:*

I am permitted to sign for the patient as I am their legal guardian/medical power of attorney/decision maker.
My name is First Name* Last Name*, and my relationship to the patient is .
blank*
Patient's Name*

First NameLast Name
Patient's Date of Birth (MM-DD-YYYY):*
Should be Empty:

Durable Medical Equipment (DME) Form

You are being given the following forms which are required in order for you to receive your equipment. Scroll down to the bottom of the page to sign that you have agreed to the forms.

Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Supplier Standards

PATIENTS' RIGHTS AND RESPONSIBILITIES

PROTOCOL FOR RESOLVING COMPLAINTS FROM MEDICARE BENEFICIARIES

PLAN OF CARE

ADVANCE BENEFICIARY NOTICE (ABN)

DELIVERY/ PICK-UP CONFIRMATION

Same or Similar Information

PATIENT DISCLOSURE FORM

SIGNATURE AGREEMENT FOR CONSENT TO RELEASE, ASSIGNMENT OF BENEFITS, SAME OR SIMILAR AND NON-COVERAGE