1. PATIENT INFORMATION

TODAY’S DATE:

2. PLEASE COMPLETE THIS SECTION IF SOMEONE OTHER THAN
PATIENT IS RESPONSIBLE FOR SERVICES

3. WORKER’S COMPENSATION

4. ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION

I, the undersigned, have insurance with and assign directly to Fountain Orthotics and Prosthetics, Inc. all medical benefits, if any, otherwise payable to me for service rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Fountain Orthotics and Prosthetics, Inc. to access/obtain/release any medical information/records on file necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.

5. WAIVER FORM

I, understand that my eligibility for coverage by cannot be determined at this time. I wish to receive medical services from Fountain Orthotics and Prosthetics. If it is determined that I am not eligible for coverage, I understand that I will be responsible for payment of all services provided.

Print Name

Signature of Insured/Guardian

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Date

ASSIGNMENT OF BENEFITS AND MEDICAL RELEASE OF INFORMATION MEDICARE AUTHORIZATION

  • I request that payment of authorized Medicare benefits be made to Fountain Orthotics & Prosthetics, Inc. for any services rendered.
  • I authorize any holder of medical information to release requested medical information to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.
  • I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim.
  • If “other health insurance” is indicated in item 9 of HCFA –CMS1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown.
  • In Medicare assignment cases, the supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier.

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Signature of Patient or Representative


Printed Name

Title of Representative

Date

Insurance Information

Fountain Orthotics and Prosthetics is requesting that you provide ALL insurance information and insurance cards at the time of service.

It is your responsibility to provide complete insurance information so that Fountain Orthotics and Prosthetics may bill your insurance(s) on your behalf. Failure to provide this information may result in you, and /or the member, being financially responsible for any and all outstanding balance(s) due.

Fountain Orthotics and Prosthetics is not responsible for any failure on your part to provide any and all correct and current insurance information. It is unlawful for Fountain Orthotics and Prosthetics to “back date” your date of service; therefore, it is imperative that you provide all necessary information no later than by your final fitting appointment.

Please understand that insurance companies base its decisions upon the dates of service as well as timely filing, so it is imperative that all insurance information is correct, current, up to date and complete. Thank you for your cooperation and assistance.

I fully understand and acknowledge the term and provisions regarding my responsibility as stated above.

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click while signing, if you are on
mobile please use your finger.

Patient/Legal Guardian Signature


Date

ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES

This form will be retained in your medical record

By my signature below I, , acknowledge that I received a copy of the Notice of Privacy Practices for Fountain Orthotics & Prosthetics, Inc.

I hereby designate the following individual(s) to receive communications from Fountain Orthotics & Prosthetics, Inc. that may include health information about me:

Name:
Relationship:
Phone:


If this acknowledgement is signed by a personal representative, complete the following:

Personal Representative’s name:
Relationship to Patient:

I authorize Fountain Orthotics and Prosthetics, Inc. to leave voice mail messages concerning my health information at the following number:


Patient Name (Printed)

Phone:

Date

Signature

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Signature of Insured/Guardian

*This signature will be used to verify identity with regards to PHI (Protected Health Information)

For Office Use Only

I attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Employee Name

Date

Photo Release

Patient Name:
DOB:
Parent or Legal Guardian:

I consent to have MY (OR my child or an individual to whom I provide guardianship) image to be taken by the staff at Fountain Orthotics and Prosthetics as described below.

I understand that my (or child or an individual to whom I provide guardianship) photographs, videotapes, digital, and other images may be recorded to document and assist with my care and the payment of my bill (or child or an individual to whom I provide guardianship). These images may be used to assist in the education of students and residents within the institution. I understand that the Fountain Orthotics and Prosthetics will own these images, but that I will be allowed access to view them or to obtain copies of them at a reasonable cost. Other than for treatment, education, and payment purposes, images that identify me (or child or an individual to whom I provide guardianship) will be released and/or used outside the organization only upon written authorization from me or the patient representative.

I may revoke or withdraw this consent at any time. Such withdrawal of consent must be made in writing. Withdrawal of consent does not affect any information disclosed prior to the written notice of withdrawal.

I release and hold harmless Fountain Orthotics and Prosthetics and its staff and employees from any and all claims or causes of action that I may have of any nature whatsoever, which may in any manner result from the use of the photograph or other image.

By signing below, I am indicating that I have read and understand the “Consent for Photography” form. I am either the patient or have the authority to give consent for the patient. My questions regarding this consent have been answered.

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click while signing, if you are on
mobile please use your finger.

Patient or Patient Representative Signature


Date

If Patient Representative, Relationship to Patient

Printed Name

MEDICAL RECORDS RELEASE FORM

I authorize the release of my confidential health information by releasing a copy of my
medical records to
Fountain Orthotics & Prosthetics.

Patient Name :
Date of Birth:
Signature:

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click while signing, if you are on
mobile please use your finger.
Date:

For Office Use Only

Fountain Orthotics & Prosthetics is requesting the following documents:

Acknowledgement of Financial Responsibility Form

Provider:
Fountain Orthotics & Prosthetics

Member Acknowledgment of
Financial Responsibility

Member
Financial
Arrangement

This form is used for health insurance members who wish to receive healthcare services from Fountain Orthotics & Prosthetics that may not be covered by your health insurance benefit plan.

Your signature on this form acknowledges that you agree to bear full financial responsibility for all services provided as listed below:

  • The services that are not covered under your health insurance benefit plan, or,
  • the services that have not been otherwise approved for payment by your health insurance
  • INSURANCE IS NOT A GUARANTEE OF PAYMENT

Disclaimer

Insurance coverage is estimated – your actual indemnity may be more or less. You, the patient, are responsible for all amounts not covered by your insurance carrier. Year-ToDate used benefits and remaining deductible amounts are not affected until the procedure is completed and therefore are not used in this determination of benefits.

Fountain O & P charges two percent (2%) charge for all balances not paid within three (3) months.

Member or Member’s
Legal Representative Name (Please Print)

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Member or Member’s
Legal Representative Signature


Date:

FOR QUESTIONS, CONTACT YOUR HEALTH INSURANCE MEMBER SERVICES AT THE NUMBER LOCATED ON YOUR HEALTH INSURANCE CARD.

MEDICARE DMEPOS SUPPLIER STANDARDS

Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, 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 requirements.

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 Clearinghouse within 30 days.

3. A supplier must have an authorized individual (whose signature is binding) sign the enrollment application for billing privileges.

4. A supplier must fill orders from its own inventory, or contract with other companies for the purchase of items necessary to fill orders. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or any other Federal procurement or nonprocurement 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 must maintain a physical facility on an appropriate site and must maintain a visible sign with posted hours of operation. The location must be 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.

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 use of a 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 $300,000 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 is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition see 42 CFR§ 424.57 (c) (11).

12. A supplier is responsible for delivery of and must instruct beneficiaries on the use of Medicare covered items, and maintain proof of delivery and beneficiary instruction.

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 cost either directly, or through a service contract with another company, any 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 fitted and rented or sold) from beneficiaries.

16. A supplier must disclose these standards to each beneficiary it supplies a Medicare-covered item.

17. A supplier must disclose 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 these 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 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 for those specific products and services (except for certain exempt pharmaceuticals).

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 enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.

26. A supplier must meet the surety bond requirements specified in 42 CFR § 424.57 (d).

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 CFR § 424.516(f).

29. A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers.

30. A supplier must remain open to the public for a minimum of 30 hours per week except physicians (as defined in section 1848(j)(3) of the Act) or physical and occupational therapists or a DMEPOS supplier working with custom made orthotics and prosthetics.