CLIENT/PATIENT MEDICARE BILLING SERVICE AGREEMENT

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone #*

Email*

example@example.com

Date of Birth*

Date

Gender*

Client/patient Height*

Client/patient: Weight*

Related Diagnoses for Service(s) Requested*

Client/Patient Currently Hospitalized?*

YesNo

Name of Hospital

Hospital Phone #

Does anyone smoke in the home?*

Number of people living in home including yourself?*

Emergency Contact Name*

Emergency Contact Address*

Street Address

Street Address Line 2

CityState

Zip Code

Emergency Contact Phone*

Next of Kin/Legal Guardian

Next of Kin/Legal Guardian Phone

Primary Caregiver,

Person Responsible for Bill

Primary Insurance?*

Medicare ID Number*

Name of Secondary Insurance?

Secondary Insurance Policy#

Secondary Insurance Phone #

Ordering/Prescribing Physician Name*

Ordering/Prescribing Physician Address*

Street Address

Street Address Line 2

CityState

Zip Code

Ordering/Prescribing Physician Phone Number*

Please enter a valid phone number.

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 Hazlet Pharmacy Inc. 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 to Hazlet Pharmacy Inc., Inc for any home medical equipment, supplies and services furnished to me in conjunction with my home care. I authorize Hazlet Pharmacy Inc. to seek such benefits and payments on my behalf. It is understood that, as a courtesy, Hazlet Pharmacy Inc. will bill Medicare/Medicaid or other federally funded sources and other payors and insurer(s) providing coverage, with a copy to Hazlet Pharmacy Inc. I understand that I am responsible for providing all necessary information and for making sure all certification and enrollment requirements are fulfilled. changes in the policy must be reported to Hazlet Pharmacy Inc. within 30 days of the event. I have been informed by Hazlet Pharmacy Inc. 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 Hazlet Pharmacy Inc., the prescribing physician, hospital, and any other holder of information relevant to service, to release information upon request, to Hazlet Pharmacy Inc., any payor source, physician, or any other medical personnel or agency involved with service. I also authorize Hazlet Pharmacy Inc. to review medical history and payor 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, Hazlet Pharmacy Inc. does not receive payment from my payor source, I hereby agree to pay Hazlet Pharmacy Inc. 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 payor unless my agreement with my health plan holds me harmless.

Returned Goods: I understand that, due to Federal and State Pharmacy 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. Hazlet Pharmacy Inc. 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.

Client/Patient Handouts: I acknowledge that I have received a copy of the Client/patient Handouts which contains Client/patient Rightsand Responsibilities, Supplier Standards, Home Safety Information, HIPPA Privacy Standards, Emergency Planning, and Advance Directive Information. I acknowledge that the information in the Client/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 Hazlet Pharmacy Inc. with a copy of such document.

Grievance 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 732-264-3310 and speak to the Customer Services Supervisor. 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 7 working days of receipt.

Home Health Hotline: You may also make inquiries or complaints about this company by calling your local Social Services Department and/or ACHC.

I acknowledge training in the use of equipment and products provided and the performance of the Equipment Management Admission Assessment and Plan of Service on the date noted.

I Agree*

yes

Credit Card Authorization for deductibles, copays, cost sharing as determined by Medicare and my Secondary coverage: I hereby authorize Hazlet Pharmacy Inc. to charge my credit card for the amounts determined that I owe by Medicare and my secondary coverage, after billing for services rendered. These amounts may be copays, deductibles, or other cost sharing that could not be determined prior to submitting claims for the services. I understand that these amounts are owed by me, and by signing below, I authorize Hazlet Pharmacy to charge them to my credit card. For services that are recurring, I give this same authorization for each time the service is billed to Medicare and my secondary insurance.

Please acknowledge that you agree with and understand the Credit Card Authorization Above*

We cannot bill your medical insurance for services rendered, if you do not agree to establish a payment method for the services in the event that your insurance determines there is a balance that you are required to pay.

I Have Read and Agree to all of the above Statements*

Clear

Date Signed*

Date

CLIENT/PATIENT SERVICE AGREEMENT

Patient Information

Insurance Information

Prescriber Information

Signature

Kindly Read and Attest to the following Statements by Signing Below