GRIEVANCE REPORTING: I acknowledge that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call: (954) 978-8287 and speak with facility manager on duty. If your complaint is not resolved to your satisfaction within five (5) business days, you may initiate a formal grievance in writing and forward it to:
A Fitting Experience 2950 N. State Rd. 7 Suite #103 Margate, Florida 33063
ATTN.: GOVERNING BODY
Thank You for choosing A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. as your specialty provider. We are honored by your choice and are committed to providing you with the highest quality products and services. We look forward to establishing a lasting relationship. As part of this relationship, we have outlined our expectation for your financial responsibility. Please read this document thoroughly and if you have any questions, please feel free to contact our office staff at (954) 978-8287.
- YOUR RESPONSIBILITY begins when you call to make an appointment. Please know your insurance. Be aware of what they pay for and do not pay for, as well as any co-pay and deductibles.
- COPAYMENTS AND DEDUCTIBLES: Co-pays are collected at the time of check-in. Insurance deductibles and fees for services not covered by your insurance policy, if known, are due at the time the service and merchandise is rendered. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your portion due. We accept Cash, Check, and most major credit cards.
- UNPAID BALANCES: Unpaid balances are ultimately the responsibility of the insured.
- APPOINTMENT CANCELLATION POLICY: In most cases, our Staff works diligently works to obtain Referrals, Authorizations, Prescriptions and Medical Records on your behalf. Should you need to cancel your appointment, a new scheduled appointment must be made within 10 business days or a $25.00 Fee will be charged/billed directly to you.
CLIENT PATIENT HANDOUTS I acknowledge that I have been made available a copy of each:
- *SUPPLIER STANDARDS-Full text of standards may be found at: http://ecfr.gpoaccess.gov
- HIPAA PRIVACY STANDARDS
- PATIENT RIGHTS AND RESPONSIBILITIES
- CARE/USE/PRODUCT WARRANTY COVERAGE
- PRODUCT SAFETY:
- Your new products meet the specifications of your current prescription/referral.
- Have been checked for structural safety.
- All manufacturer guidelines are followed.