NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
ASSIGNMENT OF BENEFITS FORM
(FOR ACCIDENTS OCCURRING ON AND AFTER 3/1/02)
I hereby assign to Park Avenue Orthotics, Inc. all rights privileges and remedies to payment for health care services provided by assignee to which I am entitled under Article 51 (the No-Fault statute) of the Insurance Law.
The Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and shall not pursue payment directly from the Assignor for services provided by said Assignee for injuries sustained due to the motor vehicle accident, not withstanding any other agreement to the contrary.
This agreement may be revoked by the assignee when benefits are not payable based upon the assignor’s lack of coverage and/or violation of a policy condition due to the actions or conduct of the assignor.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
DELIVERY RECEIPT AND AUTHORIZATION TO RELEASE INFORMATION AND PERMIT PAYMENT OF INSURANCE BENEFITS TO PROVIDER, PARK AVENUE ORTHOTICS, INC.
I authorize my physician to release to Park Avenue Orthotics, Inc. and for Park Avenue Orthotics, Inc. to release to my insurance carrier any needed information for this or a related claim. I request that payment of authorized benefits be made on my behalf, and I assign the benefits payable for the medical equipment provided by Park Avenue Orthotics, Inc. to Park Avenue Orthotics, Inc. Although I recognize that I have primary responsibility for contacting and submitting claims to my insurance carrier, I have received the equipment and authorize Park Avenue Orthotics, Inc. to submit a claim to my insurance carrier. I understand that I am responsible for any unpaid balances, including deductibles and co-insurance. Should my insurance carrier not provide coverage:
I understand that I am responsible for payment. I have read, understand, and agree to the above.
EQUIPMENT WARRANTY INFORMATION FORM
Every orthotic device dispensed or equipment rented by Park Avenue Orthotics, Inc. carries a one year manufacturer's warranty. Park Avenue Orthotics, Inc. will notify all Medicare beneficiaries of the warranty coverage, and will honor all warranties under applicable law. Park Avenue Orthotics, Inc. will repair or replace free of charge, all Medicare covered orthotics or equipment that is under warranty. If available, an owner's manual with warranty information will be provided to beneficiaries for all durable medical equipment.
PROTOCOL FOR RESOLVING COMPLAINTS
The patient has the right to freely voice grievances and recommend changes in care or services without fear of reprisal or unreasonable interruption of services. Service, equipment, and billing complaints will be communicated to management and upper management. These complaints will be documented in the Medicare Beneficiaries Complaint Log, and completed forms will include patient’s name, address, telephone number, and health insurance claim number. A summary of the complaint, the date it was received, the name of the person receiving the complaint, and a summary of the actions taken to resolve the complaint will also be included.
All complaints will be handled in a professional manner. All logged complaints will be investigated, acted upon, and responded to in writing or by telephone by a manager within a reasonable amount of time after the receipt of the complaint. If there is no satisfactory resolution of the complaint, the next level of management will be notified progressively and up to the president or owner of the company.
The patient will be informed of this complaint resolution protocol at the time of service.
MEDICARE DMEPOS SUPPLIER STANDARDS
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).
· A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements and cannot contract with an individual or entity to provide licensed services.
· A supplier must fill orders 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.
· 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.
· 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.
· A supplier must maintain a physical facility on an appropriate site. This standard requires that the location is accessible to the public and staffed during posted hours of business, with visible signage. The location must be at least 200 square feet and contain space for storing records.
· A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards.
· 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.
· 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.
· A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from contacting a Medicare beneficiary based on a physician’s oral order unless an exception applies.
· A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.
· A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
· 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.
· 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.
· A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
· A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
· 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.
· 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. 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.
· A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.
· All suppliers must be accredited by a CMS approved accreditation organization in order to receive and retain a supplier billing number.
· All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
· All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
· All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
· A supplier must meet the surety bond requirements specified in 42 C.F.R. 424.57(c).
· A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f).
· DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.
· DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week.