• Image field 34
  • Patient Intake

  • Format: 000-000-0000.
  • By providing my phone number, I agree to receive text messages from BiliMed, L.L.C., sent from (337) 509-1818. Consent is not a condition of purchase or of renting equipment. Message frequency varies and may include order and service information (for example, order confirmations, delivery and pickup coordination, and equipment reminders). Message and data rates may apply. Reply STOP at any time to unsubscribe, or HELP for assistance, or contact support at (337) 509-1818.*
  • Baby's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Office Pickup Location - By appointment Or Choose Delivery

  • How would you like to receive your equipment?
  • Delivery fee estimate.
  • Is this delivery to your home address?*
  • Choose your preferred pickup time below. This is a request - you will receive a confirmation from BiliMed shortly to finalize your appointment time. 

  • Choose a Pickup Time*
  • EQUIPMENT RENTAL AGREEMENT

    BiliMed, L.L.C. — Home Neonatal Phototherapy Rental

    345 Doucet Road, Suite 200E, Lafayette, LA 70503 · (337) 509-1818 · info@bilimed.com

    This Equipment Rental Agreement (“Agreement”) is between BiliMed, L.L.C. (“BiliMed,” “we,” “us”) and the customer identified on the order (“Renter,” “you”). By confirming an order and electronically accepting these terms, you agree to everything below. This Agreement covers the rental of a GE BiliSoft 2.0 home phototherapy unit and its accessories (the “Equipment”) for the treatment of neonatal jaundice under a physician’s order.

    1. Order Acceptance & Right to Decline

    Your submitted order is an offer to rent. No rental exists until BiliMed accepts it and dispatches or releases the Equipment. BiliMed may decline or cancel any order at its discretion, including for incomplete information, missing physician order, payment-authorization failure, or lack of availability.

    2. Physician Order Required

    The Equipment is provided only under a valid physician order for home phototherapy. You represent that a treating physician has ordered this therapy and that you will follow the physician’s instructions and the provided how-to materials.

    3. No Availability Guarantee

    BiliMed does not guarantee that Equipment will be available at any particular time. Availability is confirmed only upon order acceptance.

    4. Rental Term & Daily Billing

    The rental begins when the Equipment is dispatched for delivery or picked up at the hub and continues until it is physically returned to BiliMed (by scheduled hub drop-off or scheduled pickup). Daily rent of $95, plus applicable Louisiana sales tax, accrues for every day the equipment is out, including the first and last day.

    Important: A physician’s stop order alone does NOT stop billing. Billing stops only when the Equipment is physically returned. There is no grace period.

    5. Rates, Payment & Good Faith Estimate

    The cash rate is $95 per calendar day, plus applicable Louisiana sales tax. BiliMed operates on a cash-pay basis and can provide a superbill for you to submit to your insurer; BiliMed does not bill Medicare or Medicaid. Consistent with the federal No Surprises Act, you may request a Good Faith Estimate of expected charges before your rental begins. If your rental is expected to continue beyond six days, BiliMed will provide you a revised Good Faith Estimate before day seven.

    6. Card Authorization Hold & Charges

    When BiliMed accepts your order you authorize a card authorization hold of $395. Equipment is not dispatched until the hold is placed. This is not a deposit and not a charge for services; it secures your obligations under this Agreement.

    Your balance accrues daily under Section 4. On the day your balance reaches $395, BiliMed applies the hold toward what you owe. BiliMed will message you before doing so. Only one hold is placed — it is never increased, stacked, or replaced with an additional hold.

    If your rental ends before your balance reaches $395, BiliMed charges the amount you owe and releases the unused portion of the hold after the Equipment is returned and inspected.

    After the hold has been applied, your balance continues to accrue at the daily rate and is charged to your card on file — either daily or in a single charge at return, at BiliMed’s option. BiliMed will message you before each charge. That message is notice to you; your authorization for these charges is given by this Agreement.

    BiliMed is not limited to $395: if amounts owed exceed the hold, you remain responsible for the balance, which BiliMed may charge to your card on file or collect by any lawful means.

    7. Delivery & Pickup

    Home delivery and pickup are optional and billed to you. The fee is $35 within 6 driving miles of the hub, plus $3 per mile beyond 6 miles, plus applicable Louisiana sales tax. Delivery and pickup are billed as separate legs. Free hub pickup and drop-off are available by appointment. A delivery attempt that cannot be completed is a billable leg, and a redelivery is an additional leg.

    8. Returns

    Returns are by appointment only. To schedule your return, call or text (337) 509-1818. Before returning, a physician stop order or a signed Against-Medical-Advice (AMA) form is required. Unattended or unscheduled drop-offs do not count as valid returns, and daily rent continues to accrue until BiliMed physically receives and logs the Equipment.

    9. Cancellations

    You may cancel free of charge before the Equipment is dispatched. If you cancel after dispatch while the Equipment is en route, you owe the full delivery fee plus one day’s rent ($95), plus applicable Louisiana sales tax. If you cancel after receiving the Equipment, daily rental charges continue to accrue under Section 4 until the Equipment is returned to BiliMed by scheduled hub appointment or scheduled pickup — cancellation alone does not stop billing.

    10. Minimum Charge

    A minimum charge of $95 (one day’s rental), plus applicable Louisiana sales tax, applies to every rental, regardless of actual use time.

    11. Late Return

    If the Equipment is returned after the agreed end date without notice, daily rent continues to accrue under Section 4 until physical return, subject to the deemed-lost provisions in Section 13.

    12. Taxes

    Louisiana state and local sales tax applies to the rental and to all related charges, including delivery, the optional damage waiver, and any cleaning or replacement fees. The combined rate is 9% — 5% Louisiana state plus 4% Lafayette. BiliMed collects and remits this tax as required by law.

    13. Deemed Lost / Unreturned & Replacement

    The replacement value of the Equipment is $4,300. Daily rent of $95, plus applicable Louisiana sales tax, accrues for every calendar day the Equipment is out until it is physically returned, and in no event will accrued daily rent exceed the $4,300 replacement value.

    Deemed lost (day 7). If the Equipment is not returned within 7 days after the expected end date, it is deemed lost, and BiliMed may charge your card on file — or bill you — the $4,300 replacement value. At that point daily rent stops accruing; the replacement charge takes its place. If your card cannot be charged in full, the $4,300 is a debt you owe BiliMed, collectible by all lawful means.

    Returned within 30 days. If you return the Equipment undamaged within 30 days of the expected end date, BiliMed will credit or remove the $4,300 replacement charge. You will still owe the daily rent for the entire period the Equipment was actually out (up to the $4,300 cap), which compensates BiliMed for the time the unit could not be rented to another family.

    After 30 days. The $4,300 replacement charge stands, the unit is considered sold/written off, and no refund is due.

    14. Equipment Care, Damage & Loss

    You bear the entire risk of loss or damage while the Equipment is in your possession. Equipment left at the delivery address in accordance with Section 7 is in your possession from the delivery time recorded by BiliMed. You are responsible for damage beyond ordinary wear and tear, and you authorize BiliMed to charge your card for repair or, if damaged beyond repair, full replacement. You may not open, service, modify, or alter the Equipment; BiliMed is responsible for all repairs and maintenance.

    Chargeable causes include, without limitation: improper use, excessive wear and tear, water damage, negligence, and loss from any cause. Accessories and disposables provided with your rental (carrying case, pad sleeves, eye shields) are included in the rental; you are responsible to replace any that are lost or damaged.

    15. Optional Damage Waiver

    For an optional one-time fee of $35, plus applicable Louisiana sales tax, BiliMed offers a Damage Waiver that limits your responsibility for unintentional (accidental) damage during the rental period. If you purchase the Waiver and covered accidental damage occurs, you pay only a flat deductible of $300 instead of the full repair or replacement cost. Whether damage is accidental rather than abuse is determined by BiliMed in its reasonable discretion.

    The Damage Waiver is not insurance; it is a contractual reduction of your liability. It does not cover: loss, theft, or failure to return the unit (you remain fully responsible under Sections 13 and 14); water damage; or accessories and disposables, which you must replace even with the Waiver.

    16. Condition at Delivery & Inspection

    You should inspect the Equipment when it is delivered or picked up and report any defect or damage to BiliMed within 2 hours. If you do not report within that period, the Equipment is deemed accepted in good working condition. The 2-hour period runs from the delivery or pickup time recorded by BiliMed or its delivery agent. No signature or acknowledgment at delivery is required for this Agreement to apply.

    BiliMed’s acceptance of returned Equipment does not represent a determination of its condition. BiliMed will inspect and determine the condition of returned Equipment within a reasonable time after receipt, and that determination is binding under Sections 13, 14, 15, and 17.

    17. Cleaning & Sanitation

    Each unit is cleaned, disinfected, and function-tested before every rental. Routine cleaning between renters is included at no charge. A cleaning fee of $40, plus applicable Louisiana sales tax, applies only if the Equipment is returned soiled or in a condition beyond normal use.

    18. Quality Assurance

    Before each rental, every unit is irradiance-tested against GE BiliSoft 2.0 targets, and the result is logged.

    19. No Customer Repairs or Alterations

    You may not repair, service, modify, or alter the Equipment, or permit anyone other than BiliMed to do so. All maintenance and repair are performed by BiliMed.

    20. Safe Use & Instructions

    You agree to use the Equipment only as directed by the treating physician and the how-to materials provided (written instructions and/or instructional video), and to keep the Equipment away from water and out of reach of anyone who might be harmed by misuse.

    21. Limitation of Liability

    BiliMed rents equipment and does not provide medical advice, diagnosis, or treatment. To the fullest extent permitted by law, BiliMed’s total liability arising out of or related to this Agreement is limited to the rental fees you paid, and BiliMed is not liable for indirect, incidental, or consequential damages. Clinical decisions remain between you and your physician.

    22. Indemnification

    You agree to indemnify and hold BiliMed harmless from claims, damages, and expenses arising from your use or misuse of the Equipment, your breach of this Agreement, or your failure to follow physician or manufacturer instructions, except to the extent caused by BiliMed’s gross negligence or willful misconduct.

    23. Assignment of Benefits (insurance, if applicable)

    If you choose to seek reimbursement from a commercial insurer, you may assign benefits to yourself and use the superbill BiliMed provides. BiliMed does not submit claims to insurers on your behalf.

    24. HIPAA & Privacy

    BiliMed collects health information about you and your baby — such as name, date of birth, contact details, the ordering physician, and the diagnosis — only as needed to provide and bill for the rental. BiliMed protects this information consistent with its Notice of Privacy Practices, which describes how your information is used and disclosed and your rights under HIPAA, and which is provided to you at intake. BiliMed does not sell your health information and shares it only as needed to provide the service — for example, with a person who delivers or picks up the Equipment, who is either trained by BiliMed and bound by a confidentiality acknowledgment, or a transport service that carries sealed packages without access to your health information — or as permitted or required by law. By accepting this Agreement, you acknowledge you have received or been offered BiliMed’s Notice of Privacy Practices.

    25. DMEPOS Supplier Standards

    BiliMed conducts its business consistent with applicable durable medical equipment supplier standards.

    26. Against Medical Advice (AMA) Return

    If you choose to discontinue therapy and return the Equipment before your physician issues a stop order, you may do so by completing an Against-Medical-Advice acknowledgment available on the BiliMed website. The completed acknowledgment must be received by BiliMed before the return is scheduled. Billing continues until the Equipment is physically returned.

    27. Default & Remedies

    Each of the following is a default under this Agreement: you fail to pay any amount when due; you fail to return the Equipment; or a payment you authorize is declined, returned, or reversed.

    If a default occurs, BiliMed may pursue all lawful remedies, including charging your card on file, requiring you to provide a valid replacement card, re-presenting any declined or returned charge, recovering the Equipment, and collecting the $4,300 replacement value and any accrued rent and fees as a debt you owe. You also agree to pay BiliMed’s reasonable costs of collection, including court costs and attorney’s fees, to the extent permitted by Louisiana law.

    28. Governing Law & Venue

    This Agreement is governed by the laws of the State of Louisiana. Venue for any dispute lies in Lafayette Parish, Louisiana.

    29. Entire Agreement & Severability

    This Agreement, together with your order and any acknowledgments, is the entire agreement between you and BiliMed. If any provision is held invalid, the remaining provisions continue in full force.

    30. Electronic Acceptance (“Confirm Order”)

    By clicking “Confirm Order” (or otherwise electronically accepting), you agree to all terms of this Agreement, and your electronic acceptance has the same legal effect as a handwritten signature. A copy will be emailed to you.

    31. Non-Waiver

    If BiliMed does not enforce a right or provision of this Agreement on any occasion, that is not a waiver of the right and does not prevent BiliMed from enforcing it later. No waiver is effective unless it is in writing and signed by BiliMed, and a waiver on one occasion does not extend to any other occasion.

    32. Bankruptcy & Insolvency

    If you become insolvent, file for bankruptcy, or have a bankruptcy proceeding filed against you while the Equipment is in your possession, BiliMed is entitled to the immediate return of the Equipment, and any unpaid rent, replacement value, and other charges under this Agreement become immediately due. The Equipment remains BiliMed’s property and is not part of your bankruptcy estate.

    33. Ownership & Financing Statement (UCC)

    This is a rental, not a sale. Title to the Equipment stays with BiliMed at all times. You authorize BiliMed to file a financing statement under the Uniform Commercial Code, or any similar notice, to record and protect BiliMed’s ownership of the Equipment while it is in your possession.

    34. Pricing & Typographical Errors

    BiliMed tries to keep all rates, fees, and descriptions accurate, but occasional typographical, clerical, or pricing errors may occur. BiliMed reserves the right to correct any such error and to cancel or decline any order affected by it, even after an order is submitted. If a corrected charge would be higher than what you were quoted, BiliMed will notify you and give you the option to cancel before proceeding.

    35. Complaints & Concerns

    If you have a concern or complaint about the Equipment or BiliMed’s service, you may contact BiliMed by phone, text, or email during posted service hours. BiliMed will acknowledge your concern, look into it, and work in good faith to resolve it promptly. Raising a concern will never affect the quality or availability of service you receive.

    36. Manufacturer’s Warranty

    The Equipment is manufactured by GE HealthCare and is covered by the manufacturer’s warranty, not by any warranty from BiliMed. To the extent allowed, BiliMed passes through to you the benefit of any applicable manufacturer’s warranty during your rental. Except for that pass-through and BiliMed’s obligation to provide a working, irradiance-tested unit at dispatch, the Equipment is provided “as is” as stated in Section 21.

    BiliMed, L.L.C. · Equipment Rental Agreement · Version 2026.08

  • GOOD FAITH ESTIMATE

    BiliMed, L.L.C. · 345 Doucet Road, Suite 200E, Lafayette, LA 70503

    (337) 509-1818 · info@bilimed.com

    Estimate of expected charges for uninsured (self-pay) patients. Required under the federal No Surprises Act.

    This is a GOOD FAITH ESTIMATE of what your rental is expected to cost. It is NOT a bill, and it is NOT a contract. You are not required to sign it or to obtain services from BiliMed. Your actual charges depend on how many days you keep the equipment, and your physician decides how long treatment continues.

    Provider

    BiliMed, L.L.C. · Service location: 345 Doucet Road, Suite 200E, Lafayette, LA 70503

    (337) 509-1818 · info@bilimed.com · NPI 1649191768 · Tax ID (EIN) 42-3523371

    Service Being Estimated

    Rental of a GE BiliSoft 2.0 home neonatal phototherapy system and its accessories (light box, fiber-optic cable, pad, pad covers, eye shields, carrying case) for the treatment of newborn jaundice under a physician's order.

    Primary service code: HCPCS E0202 (phototherapy light with photometer) · Billing basis: per calendar day

    The diagnosis code is entered from your physician's order on the written estimate we send you before your rental begins.

    Itemized Estimate

    This estimate is prepared on a four-day basis. Your physician determines how long treatment continues, so your actual number of days may be shorter or longer.

    Item or service Code Quantity Expected charge
    Home phototherapy unit rental, per calendar day E0202 4 days × $95.00 $380.00
    Cleaning, disinfection, and irradiance testing between rentals — Included $0.00
    Pad covers, eye shields, and accessories — Included $0.00
    Pickup and drop-off at our Lafayette location (by appointment) — Standard option $0.00
    Louisiana state and Lafayette sales tax on the rental — 9.00% $34.20
    ESTIMATED TOTAL — 4-day rental, hub pickup and drop-off $414.20

    Louisiana sales tax of 9.00% (5.00% state and 4.00% Lafayette) applies to equipment rentals and to the optional charges below. Tax is shown separately so you can see exactly what it is.

    What It Costs by Length of Rental

    Your physician decides how long treatment continues. This estimate reflects hub pickup and drop-off. If you choose home or hospital delivery, and/or home pickup for your return, additional trip charges apply as shown in in the pricing table below.  

    Length of rental Rental Tax Total
    2 days $190.00 $17.10 $207.10
    3 days $285.00 $25.65 $310.65
    4 days — this estimate $380.00 $34.20 $414.20

    Each additional day is $103.55, including tax.

    Optional Services (only if you choose them)

    Optional item or service Basis With tax
    Delivery to your home or hospital — per leg $35.00 flat, first 6 miles $38.15
    Additional mileage beyond 6 driving miles — per leg $3.00 per mile $3.27 / mile
    Return pickup from your home — per leg $35.00 flat, first 6 miles $38.15
    Optional damage waiver (one-time; reduces your liability for accidental damage to a $300 flat deductible; not insurance) $35.00 one-time $38.15

    Delivery and return pickup are billed as separate legs. If you choose both within 6 miles, that is $70.00 plus tax, or $76.30 total. A delivery attempt that cannot be completed is a billable leg, and a redelivery is an additional leg. Free pickup and drop-off at our Lafayette location remains available by appointment.

    Charges That Apply Only in Specific Circumstances

    These are not part of the estimate above and will not be charged unless the described situation occurs. Amounts shown include the 9.00% sales tax where it applies.

    • Additional rental days — $95.00 plus tax, or $103.55, for each additional calendar day the equipment is out, including the first and last day. Billing continues until the equipment is physically returned to BiliMed. A physician's stop order alone does not stop billing.
    • Rentals approaching a week — if your rental is still active as day seven approaches, BiliMed sends you a revised Good Faith Estimate covering the additional days. You do not need to request it.
    • Minimum charge — $95.00 plus tax, or $103.55 (one day), applies to every rental regardless of actual use time.
    • Cleaning fee — $40.00 plus tax, or $43.60, only if the equipment is returned soiled or in a condition beyond normal use. Routine cleaning is always included at no charge.
    • Damage beyond ordinary wear — repair cost, or up to the $4,300.00 replacement value if damaged beyond repair. If you purchased the damage waiver, covered accidental damage is limited to a $300.00 deductible.
    • Unreturned equipment — if the equipment is not returned within 7 days after the expected end date it is deemed lost and the $4,300.00 replacement value applies. Accrued daily rent will never exceed that amount.
    • Cancellation after dispatch — if you cancel while the equipment is en route, the delivery fee plus one day's rent applies: $38.15 plus $103.55, or $141.70 within 6 miles.

    About the $395 Card Authorization Hold

    When we accept your order we place a $395.00 authorization hold on your card. Equipment is not dispatched until the hold is placed. A hold is not a charge and it is not a deposit — it sets money aside to secure your obligations under the Rental Agreement.

    If your total stays under $395.00, we apply your actual charges and release the rest back to you.

    On the day your total passes $395.00, we apply the hold in full. The amount above $395.00 stays on your running balance. How soon this happens depends on what you chose — a rental with no delivery reaches it later than one with delivery and the damage waiver. We message you before we do it. The message is notice, not a request for permission.

    After the hold is applied, charges continue at $103.55 per day, including tax, and are billed to the card on file — either daily or in one charge when the equipment is returned. BiliMed is not limited to the $395.00 hold: if the amount you owe exceeds it, you remain responsible for the balance, which BiliMed may charge to the card on file or collect by any lawful means.

    Payment and Insurance

    BiliMed operates on a cash-pay basis. All major credit cards are accepted, including HSA and FSA cards. We do not currently bill private insurance directly, and we do not bill Medicare or Medicaid. On request we will supply you with an itemized superbill that you may submit to your insurer for possible reimbursement. Any reimbursement is between you and your insurer; BiliMed does not guarantee it.

    Items and Services Not Included in This Estimate

    This estimate covers only the equipment rental described above. It does not include any care provided by another provider — for example your pediatrician's office visits, bilirubin blood draws, laboratory fees, hospital charges, or any physician services. Those providers must give you their own separate good faith estimates on request. To obtain one, contact that provider or facility directly and ask for a good faith estimate.

    Your Rights Under the No Surprises Act

    • You have the right to receive a good faith estimate of expected charges before you receive services.
    • You have the right to receive this estimate in writing at least one business day before service. You may also ask for it any time before that.
    • If you receive a bill that is at least $400 more than this good faith estimate, you may be eligible to dispute the bill through the federal patient-provider dispute resolution process.
    • You must start the dispute process within 120 calendar days of the date on your bill.
    • Starting a dispute will not affect the quality of service you receive from BiliMed, and BiliMed will not retaliate against you for disputing a bill.
    • For questions or more information about your right to a good faith estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059.

    Important Disclaimers

    This good faith estimate shows the costs of items and services that are reasonably expected for your rental. The estimate is based on information known at the time it was created and does not include any unknown or unexpected costs that may arise during treatment. This estimate is not a contract and does not require you to obtain services from BiliMed.

    Contact Us

    BiliMed, L.L.C. · 345 Doucet Road, Suite 200E, Lafayette, LA 70503

    Phone or text: (337) 509-1818 · Email: info@bilimed.com

    Open 8:00 AM – 7:00 PM, seven days a week. Pickup and drop-off at our Lafayette location are by appointment. Home delivery and return pickup are doorstep service and require no appointment.

  • BiliMed, L.L.C.


    PATIENT RIGHTS & RESPONSIBILITIES

    345 Doucet Road, Suite 200E, Lafayette, LA 70503

    (337) 509-1818  |  info@bilimed.com


    BiliMed, L.L.C. is committed to providing safe, respectful, and reliable home phototherapy equipment rental services. This document describes what you can expect from us, and what we ask of you in return, during your rental. 


    Your Rights


    • To receive considerate, respectful service, without regard to race, creed, national origin, sex, age, disability, diagnosis, or religious affiliation.

     
    • To receive equipment that has been cleaned, disinfected, and function-tested before delivery.

     
    • To receive clear instructions on how to safely set up and use your rental equipment, including written materials and/or an instructional video.

     
    • To make informed decisions about your care, in consultation with your treating physician.

     
    • To ask questions about your rental and receive timely, courteous answers.

     
    • To have your health information protected and used only as described in our Notice of Privacy Practices.

     
    • To receive a copy of your Rental Agreement, Good Faith Estimate, and Notice of Privacy Practices.

     
    • To be treated with dignity and respect, regardless of how you choose to pay for services.

     
    • To voice a concern or complaint about your rental or our service without fear that doing so will affect the quality or availability of the care you receive.

     
    • To have equipment that proves defective or unsuitable repaired or replaced promptly.

     
    • To request an itemized superbill for submission to your health insurer.

     
    Your Responsibilities


    • To use the equipment only as directed by your treating physician and the instructions provided by BiliMed.

     
    • To keep the equipment away from water and out of reach of anyone who might be harmed by misuse.

     
    • To inspect the equipment at delivery or pickup and report any damage or defect within 2 hours.

     
    • To notify BiliMed promptly if the equipment stops working properly or is damaged.


    • To follow the return process described in your Rental Agreement, including scheduling your return by appointment.

     
    • To understand that daily rental charges continue until the equipment is physically returned to BiliMed, regardless of when your physician issues a stop order.

     

    • To provide accurate contact, billing, and physician information at the time of your order.

     

    • To care for the equipment and accessories as your own, and to understand your financial responsibility for loss or damage as described in your Rental Agreement.

     
    By checking the box below and typing your name, you acknowledge that you have received and reviewed this Patient Rights & Responsibilities handout.

  • NOTICE OF PRIVACY PRACTICES

    BiliMed, L.L.C. · 345 Doucet Road, Suite 200E, Lafayette, LA 70503 · (337) 509-1818 · info@bilimed.com

    Effective date: August 18, 2026 

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    YOUR RIGHTS

    When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

    Get a copy of your health record.
    You can ask to see or get a copy of the health information we have about you and your child. We will provide a copy or a summary, usually within 30 days of your request. If we need more time, we will tell you in writing within the first 30 days and give you the date you can expect our response. The first copy is free. If you ask for additional copies, we may charge a reasonable, cost-based fee, and we will tell you the amount before we provide them.

    Ask us to correct your health record.
    You can ask us to correct health information you think is incorrect or incomplete. We may say "no" to your request, but we'll tell you why in writing, usually within 60 days.

    Request confidential communications.
    You can ask us to contact you in a specific way (for example, home or cell phone) or to send mail to a different address. We will say "yes" to all reasonable requests.

    Ask us to limit what we use or share.
    You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.

    If you pay for a service out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.

    Get a list of those with whom we've shared information.
    You can ask for a list (accounting) of the times we've shared your health information for the six years before the date you ask, who we shared it with, and why. We will include all disclosures except those about treatment, payment, and health care operations, and certain other disclosures. We'll provide one accounting a year for free but may charge a reasonable, cost-based fee if you ask for another within 12 months.

    Get a copy of this privacy notice.
    You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide a paper copy promptly.

    Choose someone to act for you.
    If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. As a parent or legal guardian, you may act on behalf of your child. We will make sure the person has this authority and can act for you before we take any action.

    File a complaint if you feel your rights are violated.
    You can complain if you feel we have violated your rights by contacting us using the information at the top of this notice.

    You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

    We will not retaliate against you for filing a complaint.

    YOUR CHOICES

    For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information, talk to us. Tell us what you want us to do, and we will follow your instructions.

    In these cases, you have both the right and choice to tell us to:

    • Share information with your family, close friends, or others involved in your child's care;
    • Share information in a disaster relief situation.

    If you are not able to tell us your preference — for example, if you are unavailable — we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

    We never share your information for marketing purposes and never sell your information.

    HOW WE TYPICALLY USE OR SHARE YOUR HEALTH INFORMATION

    We typically use or share your health information in the following ways.

    To provide the rental and treatment support.
    We use your health information to provide and coordinate your equipment rental. Example: We use the physician's order and your child's diagnosis to dispense the correct phototherapy unit and settings, and we may share information with the ordering physician's office.

    To run our organization.
    We can use and share your health information to run our business, improve your service, and contact you when necessary. Example: We use your information to schedule delivery and pickup, to arrange cleaning and servicing of returned equipment, and to contact you about your rental.

    To bill and receive payment.
    We can use and share your health information to bill and get payment. Example: If you request an itemized superbill to submit to your health plan, it will include your information, the equipment code, and the diagnosis. You pay BiliMed directly; we do not file claims to insurers on your behalf.

    With people and companies who help us provide the service.
    We may share your information with people who perform services for us — for example, someone who delivers equipment to and from your home. Anyone working under our direction is trained and signs a confidentiality acknowledgment before handling your information. We may also use a transport service that carries sealed packages to and from your home without access to your health information. Where a company performs services for us that require access to your health information, we have a written business associate agreement with that company.

    HOW ELSE CAN WE USE OR SHARE YOUR HEALTH INFORMATION?

    We are allowed or required to share your information in other ways — usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

    • Help with public health and safety issues — such as reporting to the FDA regarding equipment safety, preventing disease, or reporting suspected abuse or neglect.
    • Comply with the law — when required by federal or state law, including with the U.S. Department of Health and Human Services if it wants to see that we're complying with federal privacy law.
    • Respond to organ and tissue donation requests, or work with a medical examiner or funeral director (rarely applicable to our service).
    • Address workers' compensation, law enforcement, and other government requests as permitted by law.
    • Respond to lawsuits and legal actions — in response to a court or administrative order, or a subpoena.

    SUBSTANCE USE DISORDER RECORDS

    In the ordinary course of our business, BiliMed does not create or receive substance use disorder (SUD) treatment records subject to 42 CFR Part 2. If we ever receive such records, we will treat them with the additional protections that law requires, including obtaining your consent before using or sharing them except as the law allows.

    OUR RESPONSIBILITIES

    • We are required by law to maintain the privacy and security of your protected health information.
    • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
    • We must follow the duties and privacy practices described in this notice and give you a copy of it.
    • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time by letting us know in writing.

    CHANGES TO THE TERMS OF THIS NOTICE

    We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

    QUESTIONS & PRIVACY OFFICIAL

    If you have questions about this notice, want more information, or want to file a complaint, contact our Privacy Official:

    Anne Orsak, Owner and Managing Officer — Privacy Official
    BiliMed, L.L.C. · 345 Doucet Road, Suite 200E, Lafayette, LA 70503
    (337) 509-1818 · info@bilimed.com

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