Authorization/Consent for Care/Service: I have been informed of the home care options available to me and of the selection of providers from which I may choose. I authorize SDS Medical Supplies under the direction of the prescribing physician, to provide home medical equipment, supplies and services as prescribed by my physician.
Assignment of Benefits/Authorization for Payment: I hereby assign all benefits and payments to be made directly SDS Medical Supplies, for any home medical equipment, supplies and services furnished to me in conjunction with my home care. I authorize SDS Medical Supplies to seek such benefits and payments on my behalf. It is understood that, as a courtesy. SDS Medical Supplies will bill Medicare/Medicaid or other federally funded sources and other payers and insurer(s) providing coverage, with a copy to SDS Medical Supplies I understand that I am responsible for providing all necessary information and for making sure all certification and enrollment requirements are fulfilled. Any changes in the policy must be reported to SDS Medical Supplies within 30 days of the event. I have been informed by SDS Medical Supplies of the medical necessity for the services prescribed by my physician. I understand that in the event services are deemed not reasonable and necessary, payment may be denied and that I will be fully responsible for payment.
Release of Information: I hereby request and authorize SDS Medical Supplies, the prescribing physician, hospital, and any other holder of information relevant to service, to release information upon request, to SDS Medical Supplies, any payer source, physician, or any other medical personnel or agency involved with service. I also authorize SDS Medical Supplies to review medical history and payer information for the purpose of providing home health care.
Financial Responsibility: I understand and agree that I am responsible for the payment of any and all sums that may become due for the services provided. These sums include, but are not limited to, all deductibles, co-payments, out-of-pocket requirements, and non-covered services. If for any reason and to any extent, SDS Medical Supplies does not receive payment from my payer source, I hereby agree to pay SDS Medical Supplies for the balance in full, within 30 days of receipt of invoice. All charges not paid within 45 days of billing date shall be assessed late charges. I am liable for all charges, including collection costs and all attorneys cost. I am responsible for all charges regardless of my payer unless my agreement with my health plan holds me harmless.
Returned Goods: I understand that, due to Federal and State Regulations ancillary items prescribed for home health care cannot be re-dispensed. Therefore, ancillary items cannot be returned for credit. Home Medical Equipment that is rented will be returned after the physician has discontinued service. Sale items cannot be returned. SDS Medical Supplies must be notified within 24 hours of the set-up if any equipment is defective. In the case of defective equipment, an exchange will be made for the defective item.
Patient Handouts: I acknowledge that I have received a copy of the Patient Handouts which contains Patient Rights and Responsibilities, Supplier Standards, Home Safety Information, HIPAA Privacy Standards, Emergency Planning, and Advance Directive Information. I acknowledge that I have received company marketing material and information on the company’s scope of services. I acknowledge that the information in the Patient Handouts has been explained to me and that I understand the information. I understand my right to formulate and to issue Advance Directives to be followed should I become incapacitated. I will furnish SDS Medical Supplies with a copy of such document.
Complaint Reporting: I acknowledge that I have been informed of the procedure to report a grievance should I become dissatisfied with any portion of my home care experience. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call (770) 285-4104 and speak to customer services. If your complaint is not resolved to your satisfaction within 5 working days, you may initiate a formal grievance, in writing and forward it to the Governing Body. You can expect a written response within 14 working days of receipt.
You may also make inquiries or complaints about this company by calling Medicare at 1-800-MEDICARE, the Accreditation Commission for Health Care (ACHC) at 919-785-1214 and/or Georgia Board of Pharmacy at Georgia Professional Licensure Complaint Form.
