Person Responsible for Payment: Enter text
Hours and Location
We are located in Austin, Texas and have flexible hours to better serve our newborn parents. Please call to arrange Pick up or Drop off. (512) 361-2232.
On Call and Emergency services
We are available 24 hours per day. If you experience problems with your machine or have questions about usage, please do not hesitate to contact us immediately at (512) 361-2232.
Patient representative (parent(s)) is/are fully responsible for the equipment provided. If the equipment is lost, misused, stolen or damaged, the representative is responsible for the rental balance due and purchase or repair of the equipment. Repair costs may include delivery fees to and from the repair facility as well as loss of use charges.
It is the representatives responsibility to notify Austin BiliBlankets of any changes in address, phone, or plan of care promptly and to arrange for pickup as soon as your pediatrician and or doctor’s office notifies you of discontinuance.
Patient representative is responsible for all fees and charges.
Austin BiliBlankets charges a daily rental fee of $150 per day. We collect $300 at the time the order is taken or the machine is picked up. Cut off time is 3PM. Machines returned after 3PM are charged an additional daily fee of $150.00. A $300 Pre-authorization on a credit or debit card will also be assessed at time of order.
When the machine is returned, we will finalize the collection of all fees.
This notice describes how information about you may be used and disclosed and how you can get access to this information. Please read it carefully!
Commitment to Privacy
We are dedicated to maintaining the privacy of your healthcare information. We are required by law to maintain the confidentiality of information that identifies you. Any use of healthcare information beyond the uses described below requires your written authorization. The Health Insurance Portability and Accountability Act (HIPAA) obligates us to provide you a copy of our Privacy Notice and how we safeguard your health information.
Your Health Information Rights
Although your health record is the physical property of the healthcare facility that compiled it, the information belongs to you.
You have the right to:
We are responsible for:
Austin BiliBlankets abides by the terms of the privacy notice currently in effect and reserves the right to revise or amend the notice, as needed, to make new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to your address on file. We will not disclose your health information without your authorization, except for treatment, payment and healthcare operations.
By signing below, I agree to the following fee structure:
I understand that I have a choice in healthcare providers and accept financial responsibility for the goods and services Austin BiliBlankets has provided me. I have received copies of all forms pertaining to the use and cleaning of the biliblanket and all questions regarding them and the terms contained in this agreement have been answered to my satisfaction.
Family member/power of attorney to complete. Reason patient cannot sign: Newborn baby.
Parent/Guardian Name Enter text Patient Name Enter text
Relationship to Patient Enter text Date Enter text