Patient Information

The company is dedicated to providing home medical equipment and clinical respiratory services to patients with the utmost quality and professionalism. The company will accept only patients whose health care needs, as identified by the referring source, can be met by the services offered by this company.

• After Hours Emergency Service: Emergency assistance for equipment problems is available to your patients/caregivers through a 24 hour phone number. Please call 911 for medical emergencies.
• Discharge Assistance: We work directly with physicians and hospitals discharge planners to ensure smooth transitions from hospital care to home care.
• Patient Instructions and Training: A trained staff of home medical equipment professionals insures that each patient is fully trained on the operation and care of equipment.
• Patient Assessment: A trained professional meets with and determines the needs of the patient with respect to the services and equipment use to ensure that services are timely and up to date.
• Delivery Service: Delivery service, set-up, and patient instructions and training are provided free from charge.
• Geographic Scope of Service: The Company will provide the services stipulated within the following geographic boundaries: a 100 mile radius surrounding the office.

• Scope of Services: An appropriate qualified health professional will compare patient needs to company services to insure that the company can fully comply with the physician’s order through the personnel, equipment, and services if provides:

Home Medical Equipment Home Respiratory Equipment

Ambulatory Accessories Aspirators/Suction Machines

Bariatric Clinical Respiratory Services

Canes CPAP and BiPAP

Crutches, Forearm Crutches Liquid Oxygen

Commodes/Shower Chairs Nebulizer Compressors

Enteral Food Pumps and Nutrition Oxygen Concentrators

Hoyer Lifts Oxygen Conserving Devices

Hospital Beds Portable Oxygen

Lift Chairs/Recliners Ventilators, Invasive & Non-Invasive

Low Air Loss Systems Cough Assist

Negative Pressure Wound Pumps Chest Vest (airway clearance device)

Orthopedic Supplies IPV

Transfer Benches Flutter Device

Walkers

Wheelchairs

Note:  Not all services are available at each branch. Contact a service representative for information.

                                              Contract/Agreement, Terms and Conditions

ACKNOWLEDGEMENT OF DELIVERY AND INSERVICE

I hereby acknowledge receipt of the items listed afore. I understand that I must notify Med South, Inc. and/or its affiliates within five (5) business days of receipt of any discrepancies about this delivery or credit will not be allowed. I further acknowledge that I have received and understand the Customer Bill of Rights and Responsibilities. I have also been given instructions on using the emergency phone number and how to file a complaint. The equipment received is clean and operating properly and I have been given verbal and/or written instructions as to the safe and appropriate storage, usage, cleaning and routine maintenance of this equipment. I have verified these instructions by a return demonstration. I have also been given instructions regarding basic Home Safety, Infection Control Procedures, and Trouble Shooting Procedures where applicable, and Medicare Supplier Standards.

• RESPONSIBILITY FOR PAYMENT. I understand that I am financially responsible to Med South, Inc. and/or its Affiliates for all charges in relation to the listed items and/or services even though I may have insurance or third-party coverage. I agree to pay this account within thirty days of notification in accordance with Med South, Inc. and/or its Affiliates policy governing the payment of all balances due. In the event of default, I waive any rights which I may have to claim exemption as to personal property in relation to this obligation and I agree to pay all costs of collections, including reasonable attorney’s fees. I further agree to reimburse Med South, Inc. and/or its Affiliates in the event of loss or damage to the equipment by fire, theft or other reasons not related to normal operations.
• AUTHORIZATION TO RELEASE INFORMATION. I hereby authorize the review of my medical records by Joint Commission or other accrediting bodies, regulatory/auditing agencies on an as needed basis.
• LESEE AGREES, REPRESENTS AND COVENTANTS AS FOLLOWS:  As leases are on a month to month basis, unless otherwise specified, beginning with original date of service ad are not subject to prorated charges upon equipment return. Lease will continue in effect until Lessee or representative of Lessee notifies Lessor that the equipment is no longer needed and arrangements are made for the return of the equipment. Leased equipment that requires a prescription from Lessee’s physician cannot be picked up or returned to Lessor without authorization from said physician except in cases of repairs and/or malfunctions, changes in prescription or failure to pay all charges associated with this lease/purchase agreement. Lessee shall pay all fees, cost or other expenses, including attorney’s fees, reasonably incurred by Lessor in collecting any unpaid rental charges from Lessee or in repossessing the leased equipment.
• LESSEE WILL NOT REMOVE: the leased equipment from the address stated in the lease agreement, except in the course of normal usage, without the prior written consent from the Lessor. All leased oxygen containers are and will remain the property of the Lessor unless otherwise stated. Lessee has received instructions for, and fully understands, the nature, use and operation of the leased equipment. Lessee is fully informed and aware of all dangers, potential for flammability and all other possible hazards incidental to the possession, use and operation of the leased equipment. Lessee shall employ proper care in the use and operation of the leased equipment, including performing routine cleaning. In the event the leased equipment is damaged, is in disrepair or otherwise becomes unsafe for the proper use and operation, Lessees shall immediately cease use of the leased equipment and notify Lessor. Lessee shall reimburse Lessor for an amount equal to the current Manufacturers’ Suggested Retail Price for any equipment lost, stolen, or destroyed while in the possession of Lessee. Lessee shall indemnify and hold harmless Lessor and its employees against any and all claims, actions, suits, proceedings, costs, expenses, damages, and any and all other liability or loss, specifically including any negligence of Lessor, incurred as a result of Lessee’s possession, use or operation of the leased equipment, or otherwise arising out of, connected with, or resulting from the manufacturer, selection, maintenance, repair, use, operation, or return of the leased equipment. Lessees waives, and Lessor disclaims, all warranties, expressed or implied, with respect to the equipment, including implied warranties of merchantability and fitness for a particular purpose, except Lessee does not waive any rights arising out of any expressed warranties given by the manufacturer of the leased equipment or any part of the leased equipment, or any rights arising out of any separate written warranty given to Lessee by Lessor.
• FOR INSURANCE CLIENTS AND BENEFICIARIES:  Lessee agrees and understands that Lessee is responsible for payment of any deductible, coinsurance, and the full amount of non-covered charges including those amounts deducted from what Medicare, Medicaid, HMO’s, PPO’s or other commercial insurers allow for leasing the equipment described on the proof of delivery. The Lessee agrees to forward within thirty days to Lessor payments received from their insurance carrier that was billed and collectible by Lessor.
• INSURANCE CARRIERS, including all of those provided, will only pay for those services that they determine to be “reasonable and necessary”. If your insurance carrier determines that a particular piece of equipment of service is not reasonable and necessary, although it would otherwise be covered, Lessee agrees to be fully responsible for payment of said equipment. Payment due Lessor will be paid immediately upon notification from insurance carrier that payment is denied and receipt of statement to Lessee from Lessor regarding same.
• LESSEE ACKNOWLEDGES that in cases when Lessor has agreed to accept assignment of insurance benefits (status subject to change) for leased/purchased equipment and has agreed to file a claim for payment for same, including both primary and co-insurance, Lessor does do as a courtesy to Lessee. In all such cases Lessee will remain responsible for the total amount for leased or purchased equipment.
• ALLOWABLE RENTAL RATES from insurance carriers such as Medicare, Medicaid, and certain commercial insurers are subject to change. It is the responsibility of your insurance carriers to notify Lessee of any such changes; however said changes will be reflected in Lessee’s monthly statement. If such rate changes are mandated by the carriers and beyond Lessor’s control, this agreement will remain legal and intact and will require no further amending other than the rate change notification from the carriers.
• LESSEE ACKNOWLEDGES and understands that failure on the part of the Lessee to comply with insurers regulations, policies and standards as required for proof of medical necessity for leased equipment including but not limited to physician’s visits, laboratory reports and tests, and necessary medical documentation will result in denial of payment for said equipment from insurer. In such cases, Lessor reserves the right to bill and collect from Lessee all monies due, starting from the original date of service. Should Lessee not comply with contractual financial obligation, Lessor reserves the right to pick up all equipment associated with this lease, regardless of the Lessee’s medical condition, and to collect all monies due during dates of service

Customer Satisfaction

As a client, you have the right to freely voice any concerns and recommend changes in care of services without fear of reprisal or unreasonable interruption in services. Service, equipment and billing concerns will be communicated to management. If you are a Medicare beneficiary, your complaint will be logged in the Medicare Beneficiaries Complaint Log and completed forms with include your contact information, a summary of the complaint and actions taken to resolve the complaint.

All concerns or complaints will be handled as follows: 

Call the company who set up/provided you with your equipment and request to speak with the Manager. Give the details of your concerns. If the Manager is unable to resolve the issue, the concern will be brought to the attention of the VP of Corporate Compliance. Resolution will be rendered in a timely fashion. If the caller is satisfied with the resolution, the case will be closed. However, if the resolution is not to the caller’s satisfaction, the matter will be directed to the President of the Company for resolution. Concerns and complaints are resolved within 14 days.

Safety or Quality Concerns

Our primary goal is to provide you with quality care in a safe environment. Your health is our top priority. To aid us in our efforts we may ask for your help. If you have a safety or quality concern we would like to know. Please contact us at 1-800-423-8677.

If your concerns are not addressed satisfactorily, please contact:

VP of Corporate Compliance, Lisa Wells

Med South, Inc. | 406 Medical Center Drive | Jasper, AL 35501

1-800-423-8677 or lwells@medsouthinc.net

If your concerns still have not been addressed to your satisfaction, you may contact:

Joint Commission on Accreditation of Healthcare Organizations

Office of Quality Monitoring

1 Renaissance Boulevard | Oakbrook Terrace, IL 60181

1-800-994-6610 or complaint@jointcommission.org

DMEPOS SUPPLIER STANDARDS

The products and/or services provided to you by Med South, Inc. and all of its Affiliates are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained from the U.S. Government Printing Office website. Upon request we will furnish you a written copy of the standards.

EQUIPMENT WARRANTY INFORMATION

Company will repair or replace free of charge any equipment that is under warranty. Company will honor all warranties under applicable law. Company will provide an owner’s manual with warranty information to patient/caregiver when this manual is available.

EMERGENCY PREPAREDNESS

Develop a personal action plan, which describes what you will do in case a natural hazard threatens your area. You should assemble a portable survival kit which includes:

• An adequate supply of medication
• Extra oxygen
• Substitute breathing equipment such as hand nebulizers, portable inhalers, etc., in case of electrical failure
• Supplies for cleaning respiratory equipment
• If you decide to stay home, phone or write your local power company and ask for a representative to explain their life sustaining equipment program (refer to your electric bill for information concerning your local power company)
• If evacuation is necessary, try to arrange transportation with friends or relatives. If that can’t be done, phone or write to the Emergency Preparedness Office (Civil Defense) and request to be placed on their disabled list
• There is a possibility that you may be without electricity and/or phone service several days or longer.
• Remember, be prepared.

Disease Prevention and Control Activities

• Wash your hands using soapy water or hand sanitizer for 10-15 seconds before eating, drinking or preparing food.

• Wash your hands after changing diapers, going to the bathroom or coming in contact with any of the things listed on this page that may carry disease.

• Keep cuts, scrapes, or wounds clean. If the injured area becomes red, swollen or hot to touch, or if you develop a fever, see your healthcare provider.

During everyday activities, disease outbreaks, and emergency events such as flooding, it is vital to know about disease control and prevention. Cover your mouth and nose with a tissue every time you cough or sneeze, and throw the tissue in a trash container. If you do not have a tissue, cough into your sleeve. Wash your hands afterwards.

ELDER ABUSE

What are the warning signs of elder abuse?  While one sign does not necessarily indicate abuse, some tell-tale signs that there could be a problem are:

• Bruises, pressure marks, broken bones, abrasions, and burns may be an indication of physical abuse, neglect, or mistreatment.
• Unexplained withdrawal from normal activities, a sudden change in alertness, and unusual depression may be indicators of emotional abuse.
• Bruises around the breasts or genital area can occur from sexual abuse.
• Sudden changes in financial situations may be the result of exploitation.
• Bedsores, unattended medical needs, poor hygiene, and unusual weight loss are indicators of possible neglect.
• Behavior such as belittling, threats, and other uses of power and control by spouses are indicators of verbal or emotional abuse.
• Strained or tense relationships, frequent arguments between the caregiver and elderly person are also signs.

Remember, it is not your role to verify that abuse is occurring, only to alert others of your suspicions. If someone is in immediate danger, call 911 or the local police for immediate help. To report elder abuse, contact the Adult Protective Services (APS) agency in the state where the elder resides. You can find the APS reporting number for each state by visiting:

• The State Resources section of the National Center on Elder Abuse website.
• The Eldercare Locator website or calling 1-800-677-1116.

ARE YOU OR A LOVED ONE AT RISK FOR FALLS?

Falls are responsible for major disabilities and death. In those over the age of 65, more than one third have at least one fall each year.

Who is at Risk of Falls?  Everyone is at risk for falling, but that risk increases as we get older. It is most likely due to changes we experience as we age, such as changes to our vision, hearing, balance, touch, arthritis, medications, loss in muscle tone (usually due to lack of exercise), poor nutrition, cognitive impairments such as Alzheimer’s. Since most falls occur in the home, basic home safety corrections can go a long way in reducing your chances of falling.

• Make sure you have good lighting, especially in hallways, bathrooms, and stairways.
• Remove rugs or make sure they have non-skid backing to prevent slipping.
• Wear sturdy, non-skid shoes. Avoid wearing loose fitting slippers that may cause you to trip.
• Install handrails in the bathtub/shower and toilet area.
• Insure proper railing for stairways.
• Make sure there are no power cords, extension cords, clutter, etc. in walking areas.

What to Do if You Fall:

• Lay still!
• Slowly move your arms and legs. Note any pain or difficulty in moving limbs.
• If you are able, slowly come up on your hands and knees. Rest.
• Slowly crawl to a near piece of sturdy furniture such as a chair or low table.
• With your hands, slowly push up to an upright position and sit down.
• Call for help (a friend, neighbor, relative) to help assist you or if you need immediate medical attention, call 911.

Med South, Inc. and Affiliates

NOTICE OF PRIVACY PRACTICES

Our Duties in Protecting Your Health Information

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.

Med South, Inc. and its Affiliates are providing this Notice of Privacy Practices because the privacy of your health information is very important to you and to us, and in compliance with federal regulations.

By “your health information” we mean your protected health 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 and other information related to your health care that we maintain about you.

We are required by law to maintain the privacy of your health information. We must inform patients or their legal representatives of our legal duties and privacy practices with respect to health information. This Notice discharges that duty, and we must abide by the terms of the Notice currently in effect.

We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that we maintain. At any time, you may obtain a copy of the current Notice from the VP of Corporate Compliance, Lisa Wells at 406 Medical Center Drive, Jasper, AL 35501.

SUMMARY

The Notice covers:

• Uses or disclosures which do not require your written authorization.
• Uses or disclosures of your information to which you may object.
• Uses or disclosures permitted or required.
• Uses or disclosures which required your written authorization.
• Your rights as a patient to privacy of your health information.
• Complaints, contact person, effective date, and acknowledgement.

Uses or Disclosures Which Do Not Require Your Written Authorization

We use or disclose your health information to carry out your treatment; to obtain payment for your treatment; and to conduct health care operations. For example:

• For Treatment: We may use your medical information and may disclose your medical information to the physicians and other health care personnel who provide, coordinate or manage your health care and any related services for your treatment. We may also disclose your medical information to another health care provider who is not located at one of our facilities, at his request, for your treatment by the other provider.
• For Payment: We may use and disclose your medical information in order to bill and collect payment for the treatment and services provided to you. For instance, we may provide portions of your medical information to your health insurance plan to get paid for the health care services we provided to you. We may also disclose your medical information to your health insurance plan to permit it to make a determination of eligibility or coverage for insurance benefits, to review the services we provided to you for medical necessity, and to perform utilization review activities. We may also disclose medical information about you to the responsible party of your account. If you are listed as a dependent on another person’s insurance policy, financial information regarding medical care provided may be mailed to that responsible party. In addition, if you do not timely pay us for the health care services we provided to you, we may also disclose limited medical information to a collection agency. We may also disclose your medical information to other health care providers, health plans or health care clearinghouses for their payment activities.
• For Health Care Operations: We may use and disclose your medical information in order to support our business activities, such as quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for our other business activities. For example, we may use your medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose your medical information to medical school students who see patients at our facilities. In addition, we may use and disclose your medical information to other health care providers, health plans or health care clearinghouses for their limited health care operations, such as quality assessment activities, licensing and other health care compliance activities. 
• Business Associates: We may disclose your medical information to our business associates that assist us in our delivery of health care and related services, such as billing companies, lawyers, accountants and others.

Uses or Disclosures of Your Health Information to Which You May Object

• Facilities/Patient Directories: We may include your name, location in our facility, general condition, and religious affiliation in our patient directory at your location for use by clergy and visitors who ask for you by name unless you object in whole or in part. In an emergency situation and if you are incapacitated, you will be given the opportunity to agree or object when it becomes practicable.   
• Individuals Involved in Your Care: We may disclose your medical information to a family member, friend or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. In an emergency situation and if you are incapacitated, you will be given the opportunity to agree or object when it becomes practicable. 

Uses or Disclosures Required or Permitted

Where we are required or permitted to do so, we may use or disclose your health information in the following circumstances without your written authorization.

• Uses and Disclosures Required by Law: We may use or disclose your medical information as required by law, but must limit such use or disclosure to relevant information and otherwise comply with applicable legal requirements. We must also disclose your medical information to the Secretary of Health and Human Services to determine our compliance with federal privacy laws. 
• Public Health Activities: We may use or disclose your medical information to public health authorities authorized to receive or collect information for public health purposes, such as for preventing or controlling disease and certain regulatory activities of the Food and Drug Administration.
• Abuse, Neglect, or Domestic Violence: We may use or disclose your medical information in some instances if we reasonably believe that you are a victim of abuse, neglect, or domestic violence.
• Health Oversight Activities: We may use or disclose your medical information to a health oversight agency for health oversight activities authorized by law, including, for example, inspections and licensure of health care facilities.
• Judicial and Administrative Proceedings: We may use or disclose your medical information under certain conditions to comply with legal proceedings, such as a subpoena or order by a court or administrative tribunal.
• Law Enforcement Purposes: We may use or disclose your medical information for law enforcement purposes to law enforcement officials, such as for identification of suspects or where a crime has been committed on our premises. 
• Decedents: We may use or disclose medical information about decedents to coroners, medical examiners, funeral directors, and other individuals involved in your care.
• Organ, Eye, Tissue Donation: We may use or disclose your medical information to notify organ procurement organizations to assist them in organ, eye or tissue donation and transplants. 
• Research: In limited circumstances, we may use and disclose your medical information to conduct medical research. 
• Serious Safety Threat: We may use or disclose your medical information where we believe it is necessary to prevent or lessen a serious threat to the safety of a person or the public. 
• Special Government Functions: We may use or disclose your health information under some circumstances for specialized government functions, including those related to the armed forces, national security, and intelligence.
• Workers’ Compensation: We may use or disclose your medical information as authorized by and to the extent necessary to comply with laws related to workers’ compensation and similar programs. 
• Fundraising: We may use and disclose your medical information and the dates that you received treatment, as necessary, to contact you for fundraising activities supported by us. You have the right to opt-out of receiving such communications.
• To Your Personal Representatives: We may disclose your medical information to your personal representatives that are appointed by you or authorized by applicable law. 
• Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. We may release such information for purposes that include (1) providing you with health care; (2) protecting your health and safety or the health and safety of others; or (3) protecting the safety and security of the correctional institution.

Your Authorization Is Needed for Other Uses and Disclosures

We will not use or disclose your medical information for any other purpose unless you give us written authorization to do so. If you give us written authorization to use or disclose your medical information for a purpose that is not described in this notice, then, in most cases, you may revoke it in writing at any time. Your revocation will be effective for all your medical information that we maintain, unless we have taken action in reliance on your authorization. Below are some of the circumstances when we may use and disclose your medical information only with your authorization:

• Psychotherapy Notes: With limited exceptions, your authorization is required for use or disclosure of psychotherapy notes, which are notes recorded by a mental health professional documenting the contents of a conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of your medical record.
• Marketing: With limited exceptions, your authorization is required for use or disclosure of your medical information for marketing purposes.
• Sale of Your Medical Information: Your authorization is required if we want to sell your medical information.

Your Rights as a Patient to Privacy of Your Health Information

The Right to Request Additional Restrictions on Uses and Disclosures of Your Medical Information. You have the right to ask that we put additional restrictions on how we use and disclose your medical information, including, in limited circumstances, the disclosure of certain medical information to your health plan when you pay out of pocket in full for a treatment you receive. We do not have to agree to your request, unless such request relates to a permissible restriction on disclosure of medical information to your health plan.

• The Right to Inspect and Copy Your Medical Information. You have the right to inspect and copy your medical information, in either paper format or electronic form. In limited circumstances, we do not have to agree to your request.
• The Right to Amend or Correct. If you believe that your medical information is incorrect or incomplete, you have the right to ask us to correct or amend the information. We will require that you submit the request in writing and explain your reasons for asking for an amendment. In some cases, we do not have to agree to your request.
• The Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters by a different means or at a different location than what we are currently doing. In limited circumstances, we do not have to agree to your request.
• Paper Copy of this Notice. You have the right to request and receive a paper copy of this Notice if you received it by email or on the Internet. 
• The Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures that we and our business associates made for certain purposes for the last six (6) years.
• The Right to Receive a Notification in the Event of Breach. You have the right to receive notification from us in the event there is a breach related to your medical information.

Complaints, Contact Person, Effective Date, and Acknowledgement

You may complain to us and to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint. You may file your complaint with our agency by writing to:

Lisa Wells, VP of Corporate Compliance

Med-South, Inc. & Affiliates

406 Medical Center Drive, Jasper, AL 35501

If you believe your protected health information has been misused, you may file a complaint with Lisa Wells at 205-221-8258.

OR, in writing to:

The Secretary of Health and Human Services

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Washington, D.C. 20201

OR, in writing to:

Office for Civil Rights, DHHS

61 Forsyth Street, SW

Suite 3B70 Atlanta, Ga. 30303-8909

(404) 562-7886

(Region IV—Al, FL, GA, KY, MS, NC, SC, TN)

OR, at website:

http://www.hhs.gov/ocr/privacy/hipaa/complain