Costume acknowledges receipt/proof of delivery of the following:
I confirm on this day I received from Absolute MED supply the product listed above and participated in the plan of care. I have also been provided a separate patient handout with the following:
(1) Information and instruction regarding proper use and care of the product:
(2) Medicare Supplier Standard:
(3) Patient Bill of Rights:
(4) Proper instruction for use care and maintenance of product provided:
(5) Provider's Notice of Privacy Practices:
(6) Warranty information:
(7) Contact information for questions and/or complaints.
Consent to Treatment: I consent to treatment by the provider. I understand and acknowledge that
(1) my care is under the supervision and control of my attending physician:
(2) my physician has prescribed the product and services noted as part of my treatment and has explained to me its risks, advantages, possible complications and alternatives, and why it is considered necessary treatment for my condition:
(3) the provider's services do not include diagnostic, prescriptive, or other functions pertaining to licensed physicians and
(4) my physician is solely responsible for diagnosing and prescribing drugs, products, and therapy for my condition and otherwise supervising and controlling my medical condition.
I further understand I may refuse to accept delivery of the product.
Assignment of Benefits, Consent to Bill and Release of Medical Information: I consent to billing by the provider and request that the payment of authorized Medicare, Medicaid, WellCare, Aetna, and/or other third-party insurance benefits, including supplemental coinsurance and Medigap policies, is made on my behalf directly to the provider for the product sold to me by the provider and identified below. I agree to provide all documents and information necessary for the provider to obtain direct payment from Medicare, Medicaid, WellCare, Aetna, or other third-party payers and hereby authorize the release of my medical information to determine and obtain insurance benefits for products and services provided to me by the provider. I agree to transfer immediately to the provider any payment made directly to me for products and/or services provided by the facility. I authorize the provider to appeal denied insurance authorization and/or benefits.
Financial Responsibility: I understand and agree that:
(1) I am financially responsible to the provider for the payment of applicable deductibles and coinsurance and any other amounts that are not covered by my insurance unless otherwise provided by laws, regulation, or DME supplier contractual relationships:
(2) the actual amount I will owe depends on my insurance plan, whether my deductible has been reached, and whether I have secondary coverage such as Medigap:
(3) if I have supplemental insurance, that plan may cover my coinsurance obligation in whole or in part:
(4) if I am unable to pay the full amount, the provider will work with me to establish a payment plan that fits within my budget and
(5) the provider has a policy regarding hardship and will assess on a case-by-case basis if a patient qualifies for financial assistance.
To apply for financial assistance or to establish a payment plan, contact Absolute MED supply for billing service at (713) 893-5004.
Email & Phone Call Acknowledgment: By providing my email address and phone number, I authorize the facility to contact me regarding care and services related to the product I have received and that it will not be used for any other purpose. Portions of the correspondence may not be encrypted; therefore, the facility cannot ensure or warrant the security of any information transmitted or received by email. For any questions regarding my rights, I will refer to the provider’s Notice of Privacy Practices.
