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NEWUPDATE // PROSORTHO
Note: Checked areas to be completed by Procare Prosthetics and Orthotics Staff.
Vocation Category: Employed Full timeEmployed Part TimeStudent Full TimeStudent Part TimeHomemakerUnemployedOn DisabilityRetiredPediatric PatientOtherOn LOAUnspecified
Marital Status MDSWOther
Person responsible for the bill if different than patient
Patient's relationship to be Insured SelfSpouseChildOther
All professional services rendered are charged to the patient (or the person financially responsible). As a service to our patients, we will be glad to file your insurance claims. The patient is responsible for all fees, regardless of Insurance coverage. I authorize payment of medical benefits directly to the medical provider(s) who have treated me or rendered services or materials. I understand that I am responsible for any amount not covered by insurance. I agree to pay any balance due, in full, within 10 days of the statement, unless other arrangements have been made in advance.
A copy of this authorization shall be as valid as the original
I certify that I have received a copy of ProCare's Notice of Privacy Practices. The Notice of Privacy Practices the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills in the performance of ProCare's health care operations. The notice of Privacy Practices also describes my rights and ProCare's duties with respect to my protected health information. The notice of Privacy Practices is available at the Reception desk and on ProCare's website at www.procarepando.com
ProCare reserves the right to change the privacy that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, asking for one at the time of my next appointment, or accessing ProCare's website
Financial Liability Agreement
If correct and accurate insurance information is provided, ProCare will attempt to verify benefits and obtain authorization before your prosthetic or orthotic device is fit. Please keep in mind that verification and authorization does not guarantee coverage and/or payment. If insurance covers your services at other than 100%, you will be required to pay the amounts not covered by your insurance at the time you receive your device(s) ("Patient Liability"). ProCare may, at its discretion, access third party data sources to assist us in evaluating your ability to pay the estimated Patient Liability portion of your account. Payment can be made by cash, credit card or check. If you are unable to pay the Patient Liability amount in full at time of device delivery, ProCare reserves the right to withhold delivery of the device until such time that terms regarding the Patient Liability portion of the bill are mutually agreed upon. If following delivery of your device the insurance company does pay at 100%, you will receive a refund for any portion not considered Patient Liability.
ProCare requires that patients agree to pay reasonable collection and/or attorney's fees and costs should it become necessary to collect payment on a past due account.
If you have an attorney handling your account due to litigation, we will be glad to provide them with copies of bills. However, ProCare is not a party to your lawsuit and requires that you pay your bill in full.
If any checks written to ProCare are returned for insufficient funds there will be a $35.00 charge. If you have any questions regarding your bill or our billing process, please call the ProCare Business Office at 770-271-5501.
The fact that I may or may not be covered by insurance does nt relieve my personal obligation to pay all fees due to ProCare Prosthetics and Orthotics.
I have read and agree to al lterms and conditions of this agreement.
Note: This is abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain andretain their billing privileges. These standards, in their entirely, are listed in 42 C.F.R 424.57(c).
1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory regulatory requirements and cannot contract with an individual or entity to provide licensed services.
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 Clearing house 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 procurement or non-procurement programs.
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 that are under warranty.
7. A supplier mus maintain a physical facility on an appropriate site. This standard requires that the location is accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.
8. A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier's compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain 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 of of beeper, answering machine, answering service or cell phone during posted business hours is prohibited.
10. A supplier must have comprehensive liability insurance in the amount of at least $300,00 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 contacting a Medicare beneficiary based on a physician's oral order unless an exception applies.
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 than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was filed 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 theses 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 organization 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). Implementation Date - October 1, 2009
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 enrolment all products and services, including the addition of new products lines for which they are seeking accreditation.
26. Must meet the safety 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. 424.516(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.
I, , being of legal age, hereby consent that any videos, photographs, and/or motion picture films in which I appear, and/or audio recordings made of my voice may be used by ProCare, its assigns of successors, in whatever means they desire, including, but not limited to: television, social media (Facebook, Youtube, etc.) and/or print media. Furthermore, I hereby consent that such photographs, films and recordings, and the original media from which they are made, whether digital or physical media, including any submitted by me, shall be ProCare's property. ProCare shall have the right to duplicate, reproduce, sell and make other uses of such images, photographs, films, recordings, plates and tapes as they may desire free and clear of any claim whatsoever on my part
I, being Parent/Guardian of , hereby consent that any videos, photographs, and/or motion picture films in which said Minor appears, and/or audio recordings made of his/her voice may be used by ProCare, its assigns or successors, in whatever means they desire, including, but not limited to: television, social media (Facebook, Youtube, etc.) and/or print media. Furthermore, I hereby consent that such photographs, films and recordings, and the original media from which they are made, whether digital or physical media, including any submitted by me, shall be ProCare's property. ProCare shall have the right to duplicate, reproduce, sell and make other uses of such images, photographs, films, recordings, plates and tapes as they may desire free and clear of any claim whatsoever on my part
IN WITNESS WHEREOF I have hereunto set my hand, in the State of Georgia, this
day of 20 .
American Academy of Orthotists & Prosthetists (AAOP)
American Orthotic & Prosthetic Association (AOPA)
Georgia Society of Orthotists & Prosthetists (GSOP)
OPIE Choice Network