Thank you for choosing Aspire Products, LLC. We are dedicated to providing high quality products and services to our patients. 

**PLEASE READ INFORMATION BELOW BEFORE COMPLETING THE FORMS**

The EMST 75 has been approved by Medicare for coverage using the HCPCS code E0484. The EMST75 is indicated and prescribed for individuals suffering with neuromuscular diseases with progressive respiratory muscle weakness, patients with chronic obstructive pulmonary disease, cystic fibrosis, head and neck cancer, stroke, spinal cord injuries, and other conditions that lead to abnormal airway clearance and weakened cough production.

MEDICARE MAY COVER THE DEVICE IF YOU MEET THE FOLLOWING CONDITIONS:

1. Your primary care provider (PCP) must sign a DME order, or prescription. In this document, your PCP must state that a required office visit occurred, that you need the EMST to help a medical condition or injury, and that the EMST is for home use. This form will be sent to you immediately upon submission. 

2. Your office visit must have taken place no more than six months before the prescription is written.

** IMPORTANT INFORMATION for patients currently residing a a Skilled Nursing Facilty (SNF): When Durable Medical Equipment (DME), Prosthetics & Orthotics and parenteral and enteral nutrition (PEN) Items are used in a SNF, Medicare shall not make separate payment for DME, since the DME is already included in the payment that the SNF receives.

To order the EMST75 – Complete all required fields and sign where indicated. Please ensure all entries are correct to avoid delays in processing. Once we verify coverage and eligibility, and obtain the dme order from your physician, your device will be shipped and the claim will be submitted. 

***If your patient's diagnosis code is not in the dropdown box, choose "other" and place the code in notes. We added the most common diagnoses for convenience.

If there are any changes to your contact information, address, insurance or doctors, please update Aspire Products immediately.

We pride ourselves on our outstanding customer service, products and care. Please contact us with any questions or comments about your supply needs or service. Our hours are Mon - Fri - 10am -4pm. Our toll free customer service line is 800-596-7220 and is open 24 hrs a day. Take a moment to browse our website: www.emst150.com to see our full product offerings.

Thank you for choosing Aspire Products, LLC. We look forward to working with you! Let's Begin!

Patient's Bill of Rights

As a patient you have the right to:

1. Choose your provider of home medical supplies and equipment. You also have the right to refuse service within the confines of the law and be given information concerning consequence of refusing services.  2.Receive a timely response from Aspire Products, LLC regarding your request for home medical supplies and equipment.  3.Be given appropriate service without discrimination due to diagnosis, race, creed, color, religion, sex, national origin, sexual preference, handicap, disability or age.  4.Be treated with courtesy and respect by all Aspire Products, LLC personnel who provide service to you, in addition to being free from physical and mental abuse, neglect and exploitative practices. 5. Be given proper identification by name and title of all Aspire Products, LLC personnel who provide service to you. 6.Be given all necessary information, in a manner you can understand, so that you will be able to give informed consent for your services. 7.Receive complete privacy and confidentiality with regard to your condition, diagnosis, records, files, and any other personal health information or pertinent data as mandated by federal HIPAA regulations.  8.Access and review your records as mandated by federal HIPAA regulations. 9.Be involved in the planning and ordering process in addition to being notified of any changes in your medical equipment and/or supply services. 10.Register any complaints regarding services with us and/or appropriate federal and state agencies without fear of discrimination or unreasonable interruption of services. Patients may call our office with any complaints, grievances, and/or recommendations for change. Patients may also call Medicare at 1-800-633-4227. (Please see the Patient Complaints/Grievances Policy included with this packet for further information on our complaint policy and procedure 11.Rent or purchase inexpensive/routinely purchased Medicare items. 12.Patients also have the right to refuse any service.

As a patient you have the responsibility to:

1. The patient should promptly notify the Aspire Products, LLC of any equipment failure or damage. 2. The patient is responsible for any equipment that is lost or stolen while in their possession and should promptly notify Aspire Products, LLC in such instances. 3.The patient should promptly notify Aspire Products, LLC of any changes to their address or telephone. 4.The patient should promptly notify the Aspire Products, LLC of discontinuance of use. 5.The patient should notify the Aspire Products, LLC of discontinuance of use. 6.Except where contrary to federal or state law, the patient is responsible for any equipment rental and sale charges which the patient’s insurance company/companies does not pay. 7.Follow instructions on the care, use and maintenance of equipment and return rental equipment in good condition. 8.Show respect and consideration for Aspire Products, LLC personnel and property. 9.Provide feedback to Aspire Products, LLC regarding service needs and expectations. 10.Read, complete & sign the Notice of Privacy Practices included with this information packet. 11.Request further information concerning anything you do not understand.

 I understand that Aspire Products, LLC  services do not include diagnostic, prescriptive or other functions typically performed by licensed physicians, and that my physician is solely responsible for diagnosing and prescribing drugs, supplies, equipment and services for my condition and otherwise supervising and controlling my medical care.

I authorize my insurer(s), and any other third party payor who provides me with coverage, to disclose to Aspire Products, LLC any information regarding such coverage, including, but not limited to, payments made by such insurer(s) or third party payor(s) to me, for home healthcare products or services rendered to me by Aspire Products, LLC, and the scope and extent of coverage available from time to time. I authorize all medical personnel to provide information to Aspire Products, LLC concerning my medical history as it may relate to my home services and health care product needs. If my primary insurance changes, I agree to notify Aspire Products, LLC.

I authorize Aspire Products, LLC to request on my behalf, and to collect directly, all public and private insurance coverage benefits due for products and services supplied by Aspire Products, LLC. In the event payments for insurance benefits are made directly to me, the payee, I will endorse all checks for payment to Aspire Products, LLC. I accept all responsibility for overpayments per statement.

Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c

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. A supplier must have an authorized individual (whose signature is binding) sign the enrollment application for billing privileges. 4. A supplier must fill orders from its own inventory, or contract with other companies for the purchase of items necessary to fill orders. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or 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 an appropriate site and must maintain a visible sign with posted hours of operation. The location must be accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records. 8. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards. 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, answering service or cell phone during posted business hours is prohibited. 10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s 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 is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition see 42 CFR § 424.57 (c) (11). 12. A supplier is responsible for delivery of and must instruct beneficiaries on the use of Medicare covered items, and maintain proof of delivery and beneficiary instruction. 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 cost either directly, or through a service contract with another company, any 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 standards to each beneficiary it supplies a Medicare-covered item. 17. A supplier must disclose 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 required by the Medicare statute and regulations. 22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment for those specific products and services (except for certain exempt pharmaceuticals). 23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened. 24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare. 25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation. 26. A supplier must meet the surety bond requirements specified in 42 CFR § 424.57 (d). 27. A supplier must obtain oxygen from a state-licensed oxygen supplier. 28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 CFR § 424.516(f). 29. A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers. 30. A supplier must remain open to the public for a minimum of 30 hours per week except physicians (as defined in section 1848(j) (3) of the Act) or physical and occupational therapists or a DMEPOS supplier working with custom made orthotics and prosthetics.

Notice of Privacy Practices. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review.

Aspire Products, LLC is required by law to maintain the privacy of Protected Health Information (PHI), to provide individuals with notice of its legal duties and privacy practices with respect to PHI, and to notify affected individuals following a breach of unsecured PHI.

Aspire Products, LLC believes that the information we gather about you is of a very private nature and we are dedicated to keeping this information confidential. The records we create in providing you with care are by law kept confidential. We are also required to inform you of our policies concerning the use and storage of Aspire's personal health information.

Electronic Copy of Electronic Medical Records: If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your PHI in the form or format you request, if it is readily producible in such form or format. If the PHI is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Aspire Products, LLC maintains the right to update our Privacy Notice. Your personal health information will always be maintained by our current policies designated in our current Privacy Notice and we must follow the privacy practices described in this Notice. Aspire Products, LLC retains the right to change its privacy practices described in this Notice at any time. A current copy of our Privacy Notice is prominently displayed in the pharmacy waiting area. If you have any comments or questions about our Privacy Notice you may call (252)764-2842

Breach notification: You have the right to be notified upon a breach of any of your unsecured PHI.

Amendments: If you feel that Aspire Products, LLC has incorrect or incomplete information, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to Gail Wiley

Notice of Privacy Practices

The following describes the manner in which we will use and disclose your personal health information. Except for the purposes listed below, we will use and disclose your health information only with your written permission. You may revoke permission at any time by writing to our privacy officer. We also will not disclose your PHI for marketing purposes, nor will we make any disclosures that constitute a sale of your PHI. We will disclose health information when required to do so by federal, state or local law.

Accounting of disclosures: You have the right to request a list of certain disclosures we made of health information for purposes other than services, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Gail Wiley

Services: We may collect and share appropriate information about you to document the medical necessity of the equipment, supplies or services we are providing. Examples include diagnosis, prescription, referral and physician or health care provider information.

Payment: We may share appropriate information about you to bill and collect payment for the health care we provide, including insurance companies and third parties, which includes family members or other financially responsible parties of which you have informed us. Examples include insurance coverage and eligibility verification. We may also release appropriate information about you to family or friends that are helping you with financial responsibilities incurred while receiving equipment, supplies or services from us.

Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to Gail Wiley. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your protected health information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

Business operations: We may use and disclose information to monitor and operate our business. Examples include satisfaction surveys, health care outcomes and utilization reporting, accreditation bodies, reports provided to any federal, state or local authority (as required by law), or to remind you of equipment, supplies or service needs.

Out-of-Pocket-Payments: If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your protected health information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

Legal requirements: We may use and disclose information about you to respond to a court or legal authoritative body that legally requests information about you. Examples include providing documents for legal subpoenas or discovery proceedings and having our staff testify about the care and services we have provided.

Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to Gail Wiley. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

I acknowledge receipt of this Notice of Information Practices

Inspect and copy: You have a right to inspect and copy health information that may be used to make decisions about your care or payment for your care. This includes medical and billing records. To inspect and copy this health information, you must make your request, in writing, to Gail Wiley. We have up to 30 days to make your protected health information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. 

Our patients are important to us. We promote open communication and respect the need for open and effective communication. If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact Gail Wiley. All complaints must be made in writing. You will not be penalized for filing a complaint. Complaints may be filed with us at the address below:

Public health: We may disclose your health information to public health or legal authorities responsible for preventing or controlling disease, injury or disability.

Data breach notification: We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your health information.

Aspire Products, LLC Attn: Gail Wiley 101 VFW Rd, Cedar Point, NC NC 28584

email:complaints@emst150.com

Our mission at Aspire Products, LLC is to offer our clients outstanding service and simplify the way that medical supplies are ordered and received. Aspire Products, LLC customer service representatives help clients determine their insurance coverage and bill the insurance(s) on their behalf. Patients are responsible for payment in accordance with our company’s terms. Assignment of Benefits to a third party does not relieve the patient of the obligation to ensure full payment. Billing third party is not an obligation, but rather a service we offer if all necessary billing information and signatures are provided.

Medicare We may accept Medicare Part B assignment, billing Medicare directly for 80% of allowed charges and billing the beneficiary the 20% payment and any deductible. We offer Electronic Claims Transmission for billing non-assigned orders. Presentation of your Health Insurance Card is necessary.

Contact with infected body fluids, such as, blood, urine, feces, mucous or the droplets sprayedinto the air when a person coughs or sneezes can spread illnesses from one person to another. Some infections are spread through items that have been contaminated by drainage frominfected sores or discharges from the nose, mouth, eyes or genital/rectal area. Controlling the spread of infections means interrupting the way illness travels from one person to another. Maintaining a clean environment helps to keep infections under control. Maintaining personal hygiene is important to your health.

· Wash your hands frequently and thoroughly

· Clean contaminated household and medical equipment thoroughly

· Meet your health needs

Good hand washing is the single most important way to control infection.

Emergency Preparedness

In case of emergency, get medical help (first aid/CPR) quickly: DIAL 911

· GIVE THE LOCATION OF THE EMERGENCY (FULL ADDRESS)

· CLEARLY EXPLAIN WHAT HAPPENED

· TELL HOW MANY PEOPLE NEED HELP

· DON’T HANG UP

Be prepared for emergencies:

1. Refill medication renewals promptly to ensure you have adequate supplies on hand.2. Be sure you have an emergency back-up source/supply for any medical equipment requiring electricity. 3. Always keep a list of emergency telephone numbers available, including your medical equipment supplier(s). 4. Have someone such as a family member or neighbor who will check on you if an emergency situation occurs. 5. Determine an evacuation route and alternatives. 6. Arrange for a friend or relative in another town to be a communication contact for theextended family. 7. Make a habit to listen to daily weather forecasts. Be aware of changing conditions. 8. Find out where the main utility switches are in your home and assign someone to turn themoff in an emergency situation. 9. Have a flashlight and extra batteries nearby for power outages. Keep extra blankets availablein case the power goes out.

I, the undersigned, acknowledge that I have read and understand the following documents provided to me from Aspire Products, LLC:

Patient’s Rights and Responsibilities  

Patient Agreement/Information Release 

Delivery Authorization

Patient Acknowledgement of Receipt 

DMEPOS Medicare Supplier Standards

Notice of Privacy Practices

Complaint Policy

Policy Billing and Payment Policy

Service Delivery and Warranty

Guidelines for Infection Protection and Safety in your home 

Emergency Preparedeness Information, including Community Resource List(when applicable)

*I have completed the documents (marked with an *) required by Aspire Products, LLC in order to initiate the services I’ve requested.