Intake Form

 

HIPPA & PRIVACY NOTICE

1.        Notice of Privacy Practice:  I acknowledge that I have been offered/received this as a copy of WMMC Notice of Privacy Practices and I understand my right to request a paper copy at any time in accor{phoneNumber}dance with the Privacy Regulations of the Health Insurance Portability Act (“HIPPA”), the notice of Privacy Practices describes WMMC company legal responsibilities with respect to my protected health information and it describe my rights under the HIPPA Privacy Regulations.

2.        Medical Information Authorization:  I hereby authorize any holder of medical information about me to release WMMC any records pertaining to my medical history, services rendered, or treatment to assist in obtaining durable medical equipment requested/needed.

3.        Permission for Disclosure and Use of Information:  I consent to release WMMC records to be reviewed by authorized representative of Medicare/Medicaid, Medicare intermediary, and/or private insurance companies for use in determining my home health benefits.  Specifically, I authorize and request WMMC to allow the individual/agency request to review my official records to examine my personal and medical records. I understand that I have the legal right by signing this consent shall be valid for whatever period of time is reasonably necessary for the individual/agency requesting to see my clinical records to fulfill the above-described purpose (s), or until I revoke this consent in writing, such a revocation of the consent shall have a prospective effect only.

ASSIGNMENT OF BENEFITS & FINANCIAL RESPONSIBILITY

1.         Authorization to Assign Benefits to Provider:  I hereby request payment of my carrier to be made on my behalf to Wonderfully Made Mastectomy Care for products and services that are provided to me.  I authorize the holder of medical information about me to release it for Medicare & Medicare Services and to its agents as its agents as the information is needed to determine these benefits payable for related services.

2.        Acknowledgement of Financial Responsibility:  While there may be insurance coverage for those services or products provided by WMMC, some relative to my therapy needs, I recognize that all services may not be covered, or that reimbursement may be less than percent of charges billed, in accordance with my policy coverage.  Therefore, I acknowledge financial responsibility for any balance owing on my account. In addition, I agree to be responsible for the full amount of the charges if no payment has been made 45 days necessary to submit the claim for services. I agree to transfer immediately to WMMC any payment directly to me for services provided by WMMC on an assiged basis.

MEDICARE SUPPLIER STANDARD STATEMENTS

1.         Medicare Beneficiary Only:  The products and or/services provided to you by WMMC are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424-57(c). These standards concern business professional and operational matters (e.g. honoring warranties and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoacess.gov.  Upon request, we will furnish you a written copy of the standards.                                                                                                                                  

PATIENT  RIGHTS

2.         Patient Bill of Rights Disclaimer of Warranties:  The customer agrees that the equipment/supplies is accepted in its “as is” conditions (having been inspected by the customer upon delivery) WMMC has not prescribed the equipment/supplies, and makes no representations or warranties of any kind, including with regard to merchantability or the fitness of the equipment/supplies for any particular purpose of the customer.

The undersigned certifies that he/she has read the foregoing, may obtain a copy thereof from WMMC, and is the patient, or is duly authorized by the patient as the patient’s general agent to execute the above and accept its terms.

Medicare Capped Rental and Inexpensive or Routinely
Purchased Items Notification for
Services on or after January 1, 2006

I received instructions and understand that Medicare defines the bras/prosthesis/ accessory item that I received as being either a capped rental or an inexpensive or routinely purchased item.

N/A FOR CAPPED RENTAL ITEMS:

• Medicare will pay a monthly rental fee for a period not to exceed 13 months, after which ownership of the equipment is transferred to the Medicare beneficiary.
• After ownership of the equipment is transferred to the Medicare beneficiary, it is the beneficiary's responsibility to arrange for any required equipment service or repair.
• Examples of this type of equipment include:
Hospital beds, wheelchairs, alternating pressure pads, air-fluidized beds, nebulizers, suction pumps, continuous airway pressure (CPAP) devices, patient lifts, and trapu.e bars.

_X__ FOR INEXPENSIVE OR ROUTINELY PURCHASED ITEMS:

• Equipment in this category can be purchased or rented; however, the total amount paid for monthly rentals cannot exceed the fee schedule purchase amount.
• Examples of this type of equipment include:
Canes, walkers, crutches, commode chairs, low pressure and positioning equalization pads, home blood glucose monitors, seat lift mechanisms, pneumatic compressors (lymphedema pumps), bed side rails, and traction equipment.
• I select the: