Med Mart is committed to exceeding our client’s expectation by providing professional service and quality products at an affordable price!
COMPANY, when used in this agreement, refers to QUEEN CITY MED MART, PATIENT refers to the person receiving medical equipment and supplies.
01. Receive reasonable coordination and continuity of services from the referring agency for home medical equipment services.
02. Receive a timely response from our company when homecare services/care is needed or requested.
03. Be informed in advance of the charges, which the patient will be responsible,
04. Have one’s property and person treated with respect, consideration, and recognition of client/patient dignity.
05. Be able to identify visiting staff members through proper identification.
06. Receive appropriate service/care without discrimination in accordance with physician orders.
07. Be informed of anticipated outcomes of service/care and of any barriers in outcome achievement.
08. The Patient retains the right to refuse Company services and assumes responsibility for any consequences resulting from that refusal of service.
09. The Patient may participate in all decisions regarding service.
10. Patient personal information will be kept confidential by the company.
11. Patient must notify company of any medical status change such as doctor’s prescription, hospitalization, acquiring an infectious disease or change of residence.
01. Patient agrees to keep the equipment in their possession and at the address, to which it was delivered unless otherwise authorized.
02. Patient agrees to use the equipment for the purposes so indicated and in compliance with the physician's prescription.
03. Patient agrees to request payment of authorized Medicare, Medicaid or other private insurance benefits are paid directly to us for any services we furnish.
04. Patient agrees not to modify the rental equipment without the prior consent.
05. Patient agrees to provide access to all rental equipment for repair/replacement, maintenance, and/or picked up of the equipment.
06. Title to the rental equipment and all parts shall remain with the Company, unless equipment is purchased and paid in full. Patient must promptly notify Company of rental equipment malfunctions or defects and allow Company Representative to enter their premises to perform repair and service. Company shall not insure or be responsible to Patient or caregiver for any personal injury or property damage relegated to any equipment, including that caused by use or improper functioning of equipment the act or omission of any third party, or by any criminal act or activity, fire or activity, fire or act of God.
07. The Patient shall return the equipment in the same condition as received at the commencement of this agreement, except for ordinary wear and tear. The Patient agrees to pay for any loss or damage to the equipment occurring while it is in the Patient's possession. The Patient agrees to accept all financial responsibility for equipment.
08. If the Patient fails to pay the balance when due, the Patient agrees to pay interest at the rate of 18% per annul, from and after the due date, and to pay all costs of collection including court costs and attorney fees.
09. A maximum of one month rental, actually paid to the company, may be applied to the purchase of a rental item.
10. Financial benefits of referrals made by the Company will be disclosed to the patient. Patient agrees to notify Company of Advance Directives (living will, DNR, etc)being in place and any changes thereof.
11. Patient and Company agrees to go to arbitration if disagreement arises between the parties.
12. In the interest of health and safety, the company retains the right to refuse delivery of service at any time
13. Patient agrees to notify the company of any hospitalization, changes in customer insurance, address, telephone number, physician, or when the medical need for the rental equipment no longer exists.
This information has been provided by Queen City Med Mart to help you plan your actions in case there is a national disaster where you live. Northeast Ohio is prone to occasional natural disasters like tornadoes and floods. All areas of the U.S. are also subject to manmade disasters such as power outages and terrorist attacks. Every client/patient receiving care or services the home should think about what they should do in the event of an emergency. Our goal is to help you plan so that we can try to provide you with the best, most consistent service possible during the emergency.
KNOW WHAT TO EXPECT
If you have recently moved to this area, take the time to find out what types or natural emergencies have occurred in the past, and what types might be expected. Find out what, if any, time of the year these emergencies are more prevalent. Find out when you should evacuate, and when you shouldn't. Your local Red Cross, local law enforcement agencies, local news and radio stations usually provide excellent information and tips for planning
KNOW WHERE TO GO
One of the most important pieces of information you should know is the location of the closest emergency shelter. These shelters are opened to the public during voluntary and mandatory evacuation times. They are usually the safest places for you to go, other than a friend or relative’s home in an unaffected area.
KNOW WHAT TO TAKE WITH YOU
If you are going to a shelter, there will be restrictions on what items you can bring with you. Not all shelters have adequate storage facilities for medications that need refrigeration. We recommend that you call ahead and find out which shelter in your area will let you bring your medications and medical supplies. In addition, let them know if you will be using medical equipment that require an electrical outlet.
HOW TO REACH US IF THERE ARE NO PHONES
How do you reach us during a natural emergency if the phone lines don’t work? How would you contact us? If there is warning of an emergency we will make every attempt to contact you and provide you with the number of our cellular phone(s). Cellular phones frequently work even when the regular land line phones do not. If you have no way to call our cellular phone, you can try to reach us by having someone you know call us from his/her cellular phone. Many time cellular phone companies set up communication centers during natural disasters. If one is set up in your area you can ask them to contact us. If the emergency was unforeseen, we will try to locate you by visiting your home, or by contacting your home nursing agency. If travel is restricted due to damage from the emergency, we will try to contact you though local law enforcement agencies.
AN OUNCE OF PREVENTION
We would much rather prepare you for an emergency ahead of time than wait until it has happened and then send you the supplies you need to do this, we need you to give us as much information as possible before the emergency. We may ask you for the name and phone number of a close family member, or a close friend or neighbor. We may ask you where you will go if an emergency occurs. Will you go to a shelter, or a relative’s home? If your doctor has instructed you to go to a hospital, which one?
HELPFUL TIPS
Get a cooler and ice or freezer gel packs to transport your medication. Get all of your medication information and teaching modules together and take them with you if you evacuate. Pack one week’s worth of supplies in a plastic lined box or waterproof tote bag or tote box. Make sure the seal is watertight. Make sure to put antibacterial soap and paper towels into your supply kit. If possible, get waterless hand disinfectant. It comes in very handy if you don’t have running water. If you are going to a friend’s or relative’s home during evacuation, leave their phone number and address with Queen City Med Mart and your home nursing agency. When you return to your home, contact your home nursing agency and Queen City Med Mart so we can visit and see what supplies you need.
FOR MORE INFOMATION
There is much more to know about planning and surviving during a natural emergency or disaster. To be ready for an emergency, contact your local American Red Cross or Emergency Management Services Agency.
AN IMPORTANT REMINDER!!
During any emergency situation, if you are unable to contact our company & you are in need of your prescribed medication, equipment or supplies you must go to the nearest emergency room or a treatment facility for treatment.
Under Federal law, every adult has the right to make certain decisions concerning his or her medical treatment. The law also allows for your rights and personal wishes to be respected even if you are to sick to make decisions yourself.
You have the right, under the certain conditions, to decide whether to accept or reject medical treatment, including whether to continue medical treatment and other procedures that would prolong your life artificially.
You may spell out these rights in a “Living Will”, containing your personal directions about life prolonging treatment in the case of serious illness that could cause death.
You may also designate another person, or surrogate, who may make decisions for you if you become physically unable to do so. This surrogate may function on your behalf for a brief time or longer, for a life threatening or a non life threatening illness. Any limits to the power of the surrogate in making decisions for you should be clearly expressed. It is advisable to name a replacement in case the person you have chosen to make decisions for you becomes unable or unwilling to do so.
If you decide to make a living will or other advance directive, it is recommended that you give a copy to your doctor, your closest relative or friend and any hospital, nursing home or other facility where you are receiving treatment or care. If you change your mind, make sure that you advise all those to whom you have given copies.
A Living Will in no way affects life insurance. Also, it cannot be required as a condition for being insured or receiving health care services. Any medical treatment used for providing comfort care or to alleviate pain will be continued. A summary like this cannot answer all of your questions or cover every circumstance. If you have questions about your particular legal situation, please talk to your lawyer. Also, talk to your health care provider about the medical issues. Let those who will be caring for you know what you have decided.
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.
This Notice Of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
Uses and Disclosures of Protected Health information: Your protected health information may be used and disclosed by our organization, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the organization, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example , we would disclose your protected health information, as necessary, to a home health agency that provide care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for equipment or supplies coverage may require that your relevant protected health information be disclosed to the health plan to obtain approval for coverage.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of our organization. These activities include, but are not limited to, quality assessment activities, employee review activities, accreditation activities, and conducting or arranging for other business activities. For example , we may disclose your protected health information to accrediting agencies as part of an accreditation survey. We may also call you by name while you are at our facility. We may use or disclose your protected health information, as necessary, to contact you to check the status of your equipment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, inmates, Military Activity, National Security, and Workers’ Compensation. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of The Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.Other permitted and required use and disclosures will be made only with your consent Authorization or Opportunity to object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or this organization has taken an action in reliance on the use or disclosure indicated in the authorization.
Your Rights: Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information: Under federal law, however, you may not inspect or copy the following records, psychotherapy notes: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information: This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Our organization is not required to agree to a restriction that you may request. If our organization believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a copy of this notice from us. Upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You may have the right to have our organization amend your protected health information: If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated to us. You may file a complaint with us by notifying our privacy contact of your complaint.
We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before April 14, 2003.
We are required by law to maintain the policy of, and provide individuals with , this notice of our legal duties and privacy practices with respect to protected health information. If you have any questions concerning or objections to this form, please ask to speak with Maria Fesman, Operations Manager, in person or by phone at (513) 733-8100 or 1-800- 950-4400. Associated companies that we may do business with , such as an answering service or delivery service are given only enough information to provide the necessary service to you. No medical information is provided.
Please feel free to call us if you have any questions about how we protect your privacy.
Our Goal Is To Always Provide You With The Highest Quality Services. We Welcome Your Comments.
Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entity, are listed in 42C.F.R. 424.57 (c).
1.A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
2.A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
3.An authorized individual (one whose signature is binding) must sign the application for billing privileges.
4.A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with other entity that is currently excluded from the Medicare program, any State Healthcare care programs, or from any other Federal procurement or non procurement program.
5.A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
6.A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State Law, and repair or replace free of charge Medicare covered items are under warranty.
7.A supplier must maintain a physical facility on an appropriate site.
8.A supplier must permit CMS, or its agents to conduct on site inspections to ascertain the suppliers compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation.
9.A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, or cell phone is prohibited.
10.A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.
11.A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business.
12.A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items and maintain proof of delivery.
13.A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
14.A supplier must maintain and replace at no charge or repair directly or through a service contract with another company, Medicare covered items it has rented to beneficiaries.
15.A supplier must accept returns of substandard (less that full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
16.A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare covered item.
17.A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
18.A supplier must not convey or reassign a supplier number; i.e. , the supplier may not sell or allow another entity to use its Medicare billing number.
19.A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
20.Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint and any actions taken to resolve it.
21.A supplier must agree to furnish CMS any information required by the Medicare Statute and implementing regulations.
22.All suppliers must be accredited by a CMS approved accreditation in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals).
23.All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
24.All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
25.All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
26.All suppliers must meet the surety bond requirements specified in 42 C.F.R. 424.57 (c ). Implementation date May 4, 2009.
27.A supplier must obtain oxygen from a state licensed oxygen supplier.
28.A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F. R. 242.516 (f).
29.DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.
30.DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.
For unresolved grievances call: Pro Seniors LTC Ombudsmans (513) 345-4160 or (800) 488-6070 For concerns about patient safety or quality of care contact: The Joint Commission One Renaissance Blvd Oak Brook Terrace, IL 60181
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 bed, nebulizers, suction pumps, patient lifts and trapeze bars.
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 received instructions and understand that Medicare defines the equipment that I received as being either a capped rental or an inexpensive or routinely purchased item.
EQUIPMENT WARRANTY INFORMATION
For Equipment Warranty:
-Every product sold or rented by our company carries a 1 year manufacturer’s warranty.
-Queen City Med Mart, Inc. will notify all Medicare beneficiaries of the warranty coverage and we will honor all warranties under applicable law.
-Queen City Med Mart, Inc. will repair or replace, free of charge, in store Medicare covered equipment that is under warranty. In addition, an owner’s manual with warranty information will be provided to beneficiaries for all durable medical equipment where this manual is available.
I have been instructed and understand the warranty coverage on the product I have received.
We accept returns or exchanges of our products following these guidelines:
1.Original Sales Receipt is presented alongside merchandise in original packaging.
2.Merchandise must be unused or undamaged
3.The return is made within 30 days of original purchase, exceptions include:
a.Lift chair, scooter, wheelchair, four wheel walker, hospital bed, and leisure bed purchases must be returned, or notice that you want to return, within 3 days of delivery
b.No return on mattresses
c.No return on clearance items – all sales final
d.No merchandise may be accepted for return if worn next to the skin, used for sanitary or hygienic purposes, or if it is disposable (supplies, underpads, diapers, lancets, creams, etc.)
e.Customized and special order items will require a 20% deposit and are non refundable
4.$45.00 fee on returned checks from the bank
5.Labor and trip charges apply after 90 days on warranty repairs
6.Refunds for credit card purchases are by credit to your account only.
7.Refunds for cash purchases of less than $50.00 are given to customer at time of return.
8.Cash purchases greater than $50.00 and all check purchases are refunded by check which is issued within 25 business days of the return. It will be mailed from our Home Office in Cincinnati, Ohio to the customer’s home address.
IMPORTANT REMINDER FOR RENTAL RETURNS:
If Med Mart bills your medical insurance for rental equipment, NOTIFY US IMMEDIATELY for return if any of the following apply:
•Patient is deceased
•You are admitted into a hospital or nursing home
•You no longer require the use of the equipment
•You receive any type of hospice care, including, but not limited to, in home hospice services, a hospice facility, or hospice services at a nursing facility.
•Rental Equipment is for the period specified and is not prorated or refundable. Only one month’s rental may be applied to a purchase. The return equipment will not eliminate or reduce the financial responsibility for the months you rented the equipment.
QUEEN CITY MED MART, INC. makes every effort to provide you with the best possible service. However on occasion problems do occur.
The patient has the right to freely voice grievances and recommend changes in care or services without fear of reprisal or unreasonable interruptions of services. Service, equipment, and billing complaints will be communicated to management and upper management. These complaints will be documented in Medicare Beneficiaries Complaint Log, and completed forms will include the patient’s name, address, telephone number, and health insurance claim number, a summary of the complaint, the date it was received, the name of the person receiving the complaint, and summary of actions taken to resolve the complaint. All complaints will be handled in a professional manner. All logged complaints will be investigated, acted upon, and responded to in writing or by telephone by a manager within a responsible amount of time after the receipt of the complaint. If there is no satisfactory resolution of the complaint, the next level of management will be notified progressively and up to the president or owner of the company. The patient will be informed of this complaint resolution protocol at the time of the set up service.
QUEEN CITY MED MART, INC. is accreditation by The Joint Commission. The Joint Commission provides an efficient complaint and investigation process for all of its accredited agencies, in addition to state and federal processes. The Joint Commission promises a prompt response to your concerns 630d792d6000. Office hours are from 8:00 am – 5:00 pm Central Standard Time.
POLICY
QUEEN CITY MED MART, INC. makes available to all clients the toll free hotline that has been activated by the United States Department of Health and Human Services. The toll free hotline is 1-800-HHS-TIPS (1-800-447-8477) and accepts calls concerning alleged fraud against Medicare and Medicaid programs.
WHERE TO CALL
For routine questions regarding orders, billing, etc., please call us between 8:00am and 5:00pm Monday through Friday. We maintain 24 hour a day availability by telephone. The local telephone numbers and/or the toll free numbers to call will be provided by the Queen City Med Mart Representatives upon their first visit.
. If you need to reach us, our normal business hours are:
Monday- Friday 9:00am to 6:00pm (Cincinnati and Dayton)
Monday- Friday 9:00am to 5:30pm (Western Hills)
Saturday 9:00am to 4:00pm (Cincinnati and Western Hills)
Saturday 9:00am to 3:00pm (Dayton)
Med Mart maintains 24 hour availability by telephone. Should a life-threatening medical emergency arise, it is suggested that the patient or caregiver contact their local emergency services number for assistance.
Our company does not discriminate against any person on the basis of race, color, religion, sex, age, national origin, disability, veteran status or any other protected status in admission, treatment, or participation in its programs, services and activities, or in employment. For further information about this policy, contact the Director of Human Resources at 513-563-4855. For TDD and TTY contact the state relay by dialing 711.
Evendale
10780 Reading Rd.Cincinnati, Ohio 45241
513-733-8100 1-800-950-4400
Western Hills
6518 Glenway Ave Unit E, Cincinnati, OH 45211
513-347-9700
Kettering
2237 South Smithville Rd. Kettering, Ohio 45420
937-256-00000 1-800-333-5100
Important! Whenever Renting Equipment (As noted under the Client/Patient Bill of Rights) Please notify your local branch
•Should you require Hospitalization Experience a change of insurance
•Go into a Rehab or Skilled Facility Change your address/phone number
•You receive any type of Hospice care, including, but not limited to, in home Hospice services, a Hospice facility, or Hospice services at a nursing facility.
BILLING HOTLINE
If you have any billing questions, please call 513-563-4855 for assistance. The Billing Center will be glad to help you Monday-Friday 8:00am to 5:00pm. Please have your account number available.
