e-Signature - Optimum Medical Equipment

Thank you for choosing Optimum Medical Equipment online eSignature service to digitally sign your Patient Packet Forms. Your signature on these forms is mandatory to ensure compliance and to continue receiving any monthly supplies. Please fill out and digitally sign each of these forms below:

1. Provider Satisfaction Survey
2. Patient Bill of Rights
3. Patient Responsibilities.

At Optimum Medical Equipment, we are committed to providing the highest quality medical supplies and equipment while being mindful of expenses.
To potentially minimize out-of-pocket expenses, please inform us of any additional insurance coverage you may have, or if you plan to change your insurance. We are here to assist you with any information updates, including changes to your address or insurance coverage.

Thank you for choosing Optimum Medical Equipment as your medical equipment and supplies provider. Please contact us at (888) 463-0701 for any assistance or questions.

EXEMPLARY PROVIDER SATISFACTION MEASURE

Patient First Name *

Patient Last Name *

Patient Phone *

Email Address(optional)

Equipment Received *Select One

New EquipmentExisting Equipment

Access, Delivery and Service

1. Equipment or supplies were delivered in a timely manner. *YESNON/A

2. Equipment or supplies were ready for patient use upon delivery. *YESNON/A

3. Received and understood instructions on proper application and use of equipment/supplies. *YESNON/A

4. Feel confident to operate or use equipment/supplies. *YESNON/A

5. Received information on my rights & responsibilities, complaint process, billing, contact information and reasons to notify the equipment/supply company. *YESNON/A

6. Response to my questions, problems, concerns were addressed in a timely manner. *YESNON/A

7. Satisfied with the equipment or supplies. *YESNON/A

8. Satisfied with the service. Would recommend to others. *YESNON/A

Comments

Employee(Optimum representative who helped you - if applicable)

Signature *

PATIENT BILL OF RIGHTS AND RESPONSIBILITIES

We believe all patients receiving services from Optimum Medical Equipments should be informed of their rights. Therefore, you are entitled to:

Receive reasonable coordination and continuity of services from the referring agency for home medical equipment services.
Receive a timely response from Optimum Medical Equipments when homecare services/care is needed or requested.
Be fully informed in advance about the service/care to be provided and any modifications to the Plan of Service/Care.
Participate in the development and periodic revision of the Plan of service/care.
Informed consent and refusal of service/care or treatment after the consequences of refusing service/care or treatment are fully presented.
Be informed in advance of the charges, including payment for service/care expected from third parties and any charges for which the patient will be responsible.
Have one’s property and person treated with respect, consideration, and recognition of patient dignity and individuality.
Be able to identify visiting staff members through proper identification.
Voice grievances/complaints or recommend changes in policy, staff or service/care without restraint, interference, coercion, discrimination or reprisal.
Choose a health care provider.
Confidentiality and privacy of all information contained in the patient record and of Protected Health Information.
Receive appropriate service/care without discrimination in accordance with physician orders.
Be informed of any financial benefits when referred to an organization.
Be fully informed of one’s responsibilities.
Be informed of provider service/care limitations.
Be informed of patient rights under state law to formulate advance care directives.
Be informed of anticipated outcomes of service/care and of any barriers in outcome achievement.

MEDICARE DMEPOS SUPPLIER STATEMENT

The products and/or services provided to you by Optimum Medical Equipments meet 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 from the U.S. Government Printing Office website. Upon request we will furnish you a written copy of the standards.

Signature *

PATIENT RESPONSIBILITIES

Patient agrees to use the equipment for the purposes so indicated and in compliance with the physician’s prescription.
Patient agrees to request payment of authorized Medicare, Medicaid, or other private insurance benefits are paid directly to Optimum Medical Equipments for any services furnished by Optimum Medical Equipments.
Patient agrees that Optimum Medical Equipments shall not insure or be responsible to the patient for any personal injury or property damage related to any equipment; including that caused by use or improper functioning of the equipment; the act or omission of any other third party, or by any criminal act or activity, war, riot, insurrection, fire or act of God.
Patient agrees that any legal fees resulting from a disagreement between the parties shall be borne by the unsuccessful party in any legal action taken.

When the patient is unable to make medical or other decisions, the family should be consulted for direction.

All staff members will understand and be able to discuss the Patient Bill of Rights and Responsibilities with the patient and caregiver(s). Each staff member will receive training during orientation and attend an annual in-service education class on the Patient Bill of Rights and Responsibilities.

What To Do If You Get Hurt:

In case of emergency, contact: Fire, Police, Ambulance: 911

Contact Optimum Medical Equipments with any questions, concerns or complaints at: (888) 463-0701 or OptimumMedEquipment.com

If you have any questions about safety that aren’t in this packet, please call u and we will be happy to give you recommendations for your individual needs.

Optimum Medical Equipment is accredited by:A.C.H.C. 139 Weston Oaks Ct. Cary, NC 27513Telephone (855) 937-2242.

Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or Opportunity to Object, unless required by law. Revised 12-03-2014

Optimum Medical Equipment will provide you with an estimate of your financial responsibility. Typically Medicare will pay 80 percent of the Medicare allowable and if you do not have secondary insurance coverage you will be responsible for the remaining 20 percent. Once your insurance company has processed your claim a bill for your portion will be sent to you.

Signature *

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