SP Medical Supply

Provision of Products: I understand that my signature on this agreement authorizes SP MEDICAL SUPPLY, LLC to provide services to me.  I also understand that the products and/or services provided to me by SP MEDICAL SUPPLY, LLC   or its’ agents are provided under the direction of my physician and that SP MEDICAL SUPPLY, LLC  is not liable for any act or omission when following the instructions of my physician.

Rental/Sales Terms:  a) Equipment rented under this agreement remains the property of SP MEDICAL SUPPLYL, LLC.  The title to the equipment does not belong to the customer until payment in full has been received.  The customer agrees to return rented equipment in the same condition, as it was when received, normal wear and tear excluded. b) Customer shall notify SP MEDICAL SUPPLY, LLC if there is a change in address, or if the patient improves so that Customer no longer needs the equipment.  Customer shall notify SP MEDICAL SUPPLY, LLC if Customer is admitted to a nursing home or hospice. c) SP MEDICAL SUPPLY, LLC shall replace or repair defective equipment in a timely manner.  The customer shall notify SP MEDICAL SUPPLY, LLC as soon as practical of any malfunction or defect in the equipment SP MEDICAL SUPPLY, LLC   shall not be responsible for incidental or consequential damage due to the customer’s failure to timely notify SP MEDICAL SUPPLY, LLC of any malfunction or defect. d) SP MEDICAL SUPPLY, LLC, offers no warranty, either expressed or implied, other than the manufacturer’s warranty.  I have been informed of any warranty on the products I am receiving. 

Release of information to SP MEDICAL SUPPLY, LLC and/or its’ billing agent, Electronic Billing Services:  I understand that my signature on this agreement authorizes any entity with medical information regarding me to release to SP MEDICAL SUPPLY, LLC and/or its’ billing agent, Electronic Billing Services, any information regarding my medical history, treatments, or other relevant medical information.

Release of information by SP MEDICAL SUPPLY, LLC and/or its’ billing agent, Electronic Billing Services to insurance payers and other entities:  I understand that my signature on this agreement authorizes SP MEDICAL SUPPLY, LLC and/or its’ billing agent, Electronic Billing Services to release my medical records to a) any authorized representative of Medicare, Public Aid, Medicare fiscal intermediary, or private health insurance company for use in determining my home health benefits. b) any authorized representative of certain local, state, or national licensing, or accrediting boards or bodies, such as the Joint Commission of the Accreditation of Health Care Organizations (JCAHO). c) certain local, state, and national entities as well as certain public utilities, for Emergency Preparedness planning purposes.  This release specifically includes the release of my clinical records.  I understand that I have the right to refuse to release my medical records, and by signing this agreement, I waive my right.  This consent is valid for whatever time period is reasonably necessary for these authorized representatives to complete these tasks and shall remain in effect until such time as I revoke it in writing.  The revocation will have a prospective application only.

Acknowledgment of My Financial Responsibility:  I understand that my insurance coverage may not pay the total cost of the products or services provided to me by SP MEDICAL SUPPLY, LLC.  I acknowledge my obligation to pay the balance between what my insurance coverage will pay and what SP MEDICAL SUPPLY, LLC can charge for these services and products.  I further acknowledge that I will be responsible, and pay within 60 days from the date that the claim was submitted to my insurance payer, for the full amount of charges associated with any products or services I receive from SP MEDICAL SUPPLY, LLC should my insurance payer deny payment for any reason (including, but not limited to, my failure to qualify for the products or services, non-coverage by my insurance payer, or my failure to provide complete and accurate information to SP MEDICAL SUPPLY, LLC necessary for billing by insurance payer.)  I agree to remit to SP MEDICAL SUPPLY, LLC any payments made directly to me by my insurance payer for products or services provided by SP MEDICAL SUPPLY, LLC on an assigned basis.  I agree to be responsible for my co-payment and annual deductible amounts.

Supplier Standards:  I have received and understand the Medicare DMEPOS Supplier Standards.

Notice of Privacy Practices:  I have received and understand my HIPAA Notice of Privacy Practices.

Patient Bill of Rights:  I have received and understand my Patient Bill of Rights.

Clients Responsibilities:  I have received and understand my Clients Responsibilities.