Bill of Patient Rights and Responsibilities

As an individual receivingservices from the provider, you are entitled to:

  • Be fully informed in     advance about care/service to be provided, including the disciplines that     furnish care and the frequency of visits, as well as any modifications to     your plan of care.
  • Be informed, in advance     of care/service being provided and your financial responsibility.
  • Receive information     about the scope of services that the organization will provide and     specific limitations on those services.
  • Participate in the     development and periodic revision of your plan of care.
  • Refuse care or     treatment after the consequences of refusing care or treatment are fully     presented.
  • Be informed of     client/patient rights under state law to formulate an Advanced Directive,     if applicable.
  • Have one’s property and     person treated with respect, consideration, and recognition of     client/patient dignity and individuality.
  • Be able to identify     visiting personnel members through proper identification.
  • Be free from     mistreatment, neglect, or verbal, mental, sexual, and physical abuse,     including injuries of unknown source, and misappropriation of     client/patient property.
  • Voice     grievances/complaints regarding treatment or care or lack of respect of     property, or recommend changes in policy, personnel, or care/service     without restraint, interference, coercion, discrimination, or reprisal.
  • Have     grievances/complaints regarding treatment of care that is (or fails to be)     furnished, or lack of respect of property investigated.
  • Confidentiality and     privacy of all information contained in your client/patient record and of     Protected Health Information (PHI).
  • Be advised on the     provider’s policies and procedures regarding the disclosure of clinical     records.
  • Choose a healthcare     provider, including an attending physician*, if applicable.
  • Receive appropriate     care without discrimination in accordance with physician’s* orders, if     applicable.
  • Be informed of any     financial benefits when referred to an organization.
  • Be fully informed of     one’s responsibilities.

*a physician or other licensedpractitioner with prescribing authority.

Your Responsibilities,you agree:

  • That rental equipment     will be used with reasonable care, not altered, or modified and returned     in good condition (normal wear and tear expected), if applicable
  • To report any     malfunctions or defects in rental equipment immediately so that repair or     replacement can be made, if applicable
  • To provide access to     rental equipment for repair/replacement or pick up, if applicable
  • To utilize equipment     provided in accordance with your physician’s orders.
  • To keep rental     equipment at the location given at the time of rental and not to remove it     to any other location unless authorized by the provider, if applicable
  • To notify provider     immediately of any hospitalizations, change in address, insurance,     telephone #, or physician information, or if you do not need the equipment     any longer, if applicable.
  • To sign an assignment     of benefit for all insurance payers to provider
  • To accept financial     responsibility for HME/supplies provided as allowed by insurance carrier.
  • To pay replacement cost     of any equipment damaged, destroyed, or lost due to misuse, abuse, or     neglect.
  • Not to modify rental equipment,     if applicable
That the title of rental equipment remains with the provider until suchtime the equipment is purchased and paid in full. That provider shall notinsure or be responsible to you for any personal injury, or property damagerelated to any equipment; including that caused by use or improper functioningof the equipment; the act or omission of any other third party, or by anycriminal act or activity, war, riot, fire or act of God. That the providerretains the right to refuse delivery of service/equipment at any time