Delivery Form and Rental Agreement

Delivery Form and Rental Agreement
Family and Provider Information
Baby's Name

First NameLast Name
Baby's DOB

MonthDayYear
Date
Provider Name

First NameLast Name
Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Name

First NameLast Name
Mother's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Email
example@example.com
Father's Name

First NameLast Name
Father's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Father's Email
example@example.com
Parent's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person Responsible for Payment: Enter text

Austin BiliBlankets Patient Handbook
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.

Equipment Responsibility

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.

Financial Responsibility

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.

We accept:
- Cash
- Zelle (info@austinbiliblankets.com)
- Visa/Mastercard

Notice of Privacy Practices - HIPAA
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:
- request a restriction on certain uses and disclosures of your information;
- obtain a paper copy of this notice of privacy practices;
- inspect and copy your health care record;
- obtain an accounting of disclosures of your health information;
- request confidential communication;
- amend your health care record;
- revoke your authorization to use or disclose health information except to the extent that actionhas already been taken.
We are responsible for:
- maintaining the privacy of your health information;
- providing you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you;
- abiding by the terms of this notice;
- notifying you that we are unable to agree to a requested restriction;
- accommodating reasonable requests you may communicate health information by alternative means.
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.

Durable Medical Equipment (DME) Therapy Consent Form & Rental Agreement
I, (guardian names below) hereby authorize Austin BiliBlankets and its representatives to provide patient with a home use phototherapy (bili) light that has been prescribed by my child's physician who has explained the nature of this treatment and I have received all of the information I desire. No warrantee or guarantee has been made as to the results of this therapy. I understand it is necessary to remain under physician supervision during the course of care.I received instructions on emergency/on-call service, compliant process, rights/responsibilities, and payments (see handbook)I received a copy and understand HIPAA Notice of Privacy Policies of Austin BiliBlankets responsibility of protected health information and my rights (see handbook)I have watched the video on the Austin BiliBlankets website that explains how to use the machine at home. I understand and have been instructed on the prescribed usage of the phototherapy system provided to me. I take full responsibility for its use and care in my home. If I choose to discontinue its use, I will do so after consulting with my child's physician. I shall not hold Austin BiliBlankets responsible for any adverse consequences of any misuse, failure to use, or discontinuation of use of the phototherapy system provided to me.I understand I am responsible for any incurred charges up to the point of return of the equipment under this rental agreement. In addition I am responsible for the condition and care of the equipment and will pay 100% of the cost of any damage, including delivery fees to/from our repair vendor, caused while in my possession.Currently Austin BiliBlankets does not accept insurance payments; therefore, it is my responsibility to confirm insurance coverage and reimbursement for the phototherapy treatment. I understand and agree that regardless of my insurance coverage and potential reimbursement, I am accepting full and complete financial responsibility for all charges.
By signing below, I agree to the following fee structure:
- Daily rate: $150 per day. Minimum of 2 day rental. Returns after 3 PM will be charged an additional day.
- Pre-authorization of $300 will be assessed on a credit/debit card at the time the order is taken.
- $300 will be collected at time of order or machine pickup. Final payment will be collected based on return date and time.
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
Signature
Should be Empty:

Delivery Form and Rental Agreement

Family and Provider Information

Austin BiliBlankets Patient Handbook

Notice of Privacy Practices - HIPAA

Durable Medical Equipment (DME) Therapy Consent Form & Rental Agreement