Authorization / Consent for Care / Service

The patient or representative signing below has been informed of the home care treatment and product options available to them and of the selection of providers from which the patient may choose. The patient further authorizes MPA Medical (“MPA Medical”) under the direction of the patient’s prescribing physician, to provide home medical equipment, supplies, and services. The patient has acknowledged that the Client/Patient Service Agreement has been explained and that the patient understands the information.

Advanced Directives (Appendix A)

The patient understands their right to formulate and to issue Advance Directives to be followed should they become incapacitated.

Assignment of Benefits / Authorization for Payment

All benefits and payments must be made directly to MPA Medical for any MPA Medical furnished home medical equipment, products, and services. MPA Medical will seek such benefits and payments on the patient’s behalf. It is understood that, as a courtesy, MPA Medical will bill Medicare/Medicaid or other federally funded sources and other payers and insurer(s) providing coverage, with a copy to MPA Medical. The patient is responsible for providing all necessary information and for making sure all certification and enrollment requirements are fulfilled. Any changes in insurance coverage must be reported to MPA Medical within 10 days of the change.

Release of Information

The patient or representative requests and authorizes MPA Medical, the prescribing physician, hospital, and any other holder of information relevant to service or equipment provided by MPA Medical, to release information upon request, to MPA Medical, any payer source, physician, or any other medical personnel or agency involved with service. The patient also authorizes MPA Medical to review medical history and payer information for the purpose of providing treatment, equipment, or products.

Financial Responsibility, Arrangements, and Health Insurance

All payment and all sums that may become due for the services or products provided are due at the time services are rendered unless payment arrangements have been approved in advance by MPA Medical staff. 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, MPA Medical does not receive payment from the patient’s payer source because the patient is no longer eligible for coverage or because the service or product is not covered, the patient’s balance will be due in full within 30 days of receipt of invoice. MPA Medical accepts cash, checks, & most major credit cards. Payments by check may be converted into electronic fund transfers and funds may be debited from your account as soon as the same day payment is received.

All patient owed charges not paid within 30 days of billing date shall be assessed late charges and are subject to legally allowable interest charges. In such an event, the patient will be liable for all charges, including collection costs and all attorneys’ fees, as applicable. Balances older than 90 days may be subject to additional collection fees and interest charges of 1.5% per month. We realize that temporary financial problems may affect timely payment to your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.

I understand if I have an unpaid balance to MPA Medical Healthcare and do not make satisfactory payment arrangements, my account may be placed with an external collection agency.

In order for MPA Medical Healthcare or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that MPA Medical Healthcare and the designated external collection agency are authorized to:

(i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me,

(ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide, and

(iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable.

Furthermore, I consent for the designated external collection agency to share personal contact and account-related information with third-party vendors to communicate account-related information via telephone, text, e-mail, and mail notification.

Financial Responsibility for Non-Covered Items

By accepting these Terms and Conditions, the patient agrees that if the patient’s insurance does not cover all items ordered, even if the item is one that the patient or the healthcare provider has good reason to think is necessary, MPA Medical will not charge the insurance company, and the patient will have financial responsibility for payment for the non-covered item(s). The patient also agrees that MPA Medical has offered alternative covered items (if any) and the cost of the non-covered item, and that the patient has then accepted financial responsibility for the non-covered item.

Returned Goods

Due to Federal and State Pharmacy Regulations, ancillary items prescribed for home health care cannot be re-dispensed and cannot be returned for credit. Sale items cannot be returned.

Consent for Contact

By signing and submitting this form, the patient or representative consents to receive phone calls, texts, e-mails, and pre-recorded messages from MPA Medical or any of its subsidiaries regarding MPA Medical products and services, at the phone number(s) or email address provided; including wireless number if provided. These calls may be generated using automated technology and normal carrier charges may apply.

Please be aware that most standard email is not a secure means of communication and your protected health information that may be contained in our emails to you will not be encrypted. This means that there is a risk that your protected health information in the emails could be intercepted and read by, or disclosed to, unauthorized third parties. Use of alternative and more secure methods of communication with us, such as telephone, fax, or the U.S. Postal Service are available to you. If you do not wish to accept the risks associated with non-secure unencrypted email communications from us containing your protected health information, please indicate that you do not wish to receive such emails from us by contacting us at 844-867-9890. If you agree to receive information from MPA Medical via email or text, you agree to accept the security and privacy risks of this type of communication.

I agree that if I consent to SMS notifications regarding my order, text alerts will be sent to the number I provide. I understand that anyone with access to the mobile phone or carrier account associated with the number I have provided will be able to see this information.

Communication with Minors

We are committed to protecting the privacy of children. MPA Medical's websites and ordering ability are not directed at users under the age of 18. If you are under the age of 18, you are not permitted to register with MPA Medical, submit personal information, or place orders.

Information for Medicare Patients

The products and/or services provided to the patient by MPA Medical 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 at https://www.cms.gov/medicare/provider-enrollment-and-certification/medicareprovidersupenroll/downloads/dmepossupplierstandards.pdf.

Upon request, we will furnish you with a written copy of the standards. On-Call / After-Hours Service. MPA Medical maintains 24-hour availability through our main telephone (fill in number).

This on-call service is free to patients/clients. Should a life-threatening medical emergency arise, the patient or caregiver should contact their local emergency services number immediately for assistance (usually 911).

Patient Complaint / Grievance Process

In the event the patient should become dissatisfied with any portion of their MPA Medical provided home care experience, a complaint may be lodged with MPA Medical without concern for reprisal, discrimination, or unreasonable interruption of service. The patient has the right to present questions or grievances to an MPA Medical staff member and to receive a response in a reasonable period of time. For concerns regarding quality of care or other services, please contact MPA Medical’s office by phone or mail. Grievances can also be reported to Medicare. All contact information and our process for handling complaints can be found below.

The following procedure details the steps that MPA Medical will take when a client’s/patient’s complaint/grievance is received:

1. Contact the person making the concern within 5 days, if contact has not already been established.

2. Determine what actions the caller feels should be initiated regarding the concern.

3. Speak with involved employees and conduct additional training as appropriate.

4. Attempt to resolve the concern to the client/patient's satisfaction.

5. Report status of activities to client/patient within two days following receipt of concern.

6. Send complaint information to the Compliance Department so they can record it to Compliant Log.

7. If the complaint remains unresolved, the Compliance Department will have a department supervisor contact the patient within 5 working days.

8. Within 14 days the company shall provide written notification to the patient of the results of the investigation.

Patient Satisfaction Surveys

MPA Medical will send patient surveys via email after the order has been shipped. Data collected/analyzed on a weekly basis. By completing our qualification form, you acknowledge that you have been informed of this patient satisfaction survey procedure.

Refer a Friend, Unstoppable, and Social Media Giveaways

The Refer A Friend Giveaway and any giveaway hosted on MPA Medical’s social media channels are open to legal residents of the fifty (50) United States and the District of Columbia. Entrants must be 18 years of age or older at the time of entry. Employees, affiliates, and advertising partners are not eligible to participate. MPA Medical will choose the winner(s) at the end of each promotion.

Electrical Safety

Make sure that all medical equipment is plugged into a properly grounded electrical outlet.

If you have to use a three-prong adapter, make sure it is properly installed by attaching the ground wire to the plug outlet screw.

Use only good quality outlet "extenders" or "power strips" with internal circuit breakers.

Don't use cheap extension cords.

Safety in the Bathroom

Use non-slip rugs on the floor to prevent slipping.

Install a grab-bar on the shower wall and non-slip footing strips in the tub or shower.

Ask your medical equipment provider about a shower bench you can sit on in the shower.

If you have difficulty sitting and getting up, ask about a raised toilet seat with arm supports to make it easier to get on and off the commode.

If you have problems sensing hot and cold, you should consider lowering the temperature setting of your water heater so you don't accidentally scald yourself without realizing it.

Safety in the Bedroom

It's important to arrange a safe, well-planned, and comfortable bedroom since a lot of your recuperation and home therapy may occur there.

Ask your home medical provider about a hospital bed. These beds raise and lower so you can sit up, recline, and adjust your knees.

A variety of tables and supports are also available so you can eat, exercise, and read in bed.

Bed rails may be a good idea, especially if you have a tendency to roll in bed at night.

If you have difficulty walking, inquire about a bedside commode so you don’t have to walk to the bathroom to use the toilet.

Make sure you can easily reach the light switches and other important things you might need throughout the day or night.

Install night-lights to help you find your way in the dark at night.

If you are using an IV pole for your IV or enteral therapy, make sure that all furniture, loose carpets, and electrical cords are out of the way so you do not trip and fall while walking with the pole.

Appendix D - Emergency Planning

Every client/patient receiving care or services in the home should think about what they would do in the event of an emergency.

Our goal is to help you plan your actions in case there is a natural disaster where you live and to try to provide you with the best, most consistent service we can during an emergency.

Know what to expect:

- If you have recently moved to this area, take the time to find out what types of natural emergencies have occurred in the past, and what types might be expected.

- Find out what, if any, times of year these emergencies are most prevalent.

- Find out when you should evacuate, and when you shouldn't.

- Your local Red Cross, law enforcement agencies, local news, and radio stations provide excellent information and tips for planning.

Know where to go:

- One of the most important pieces of information you should know is the location of the closest emergency shelter.

- These shelters are open to the public during voluntary and mandatory evacuation times.

- They are usually the safest place for you to go, other than a friend or relative's home in an unaffected area.

Know what to take with you:

- Some shelters may have restrictions on what items you can bring with you. Not all shelters have adequate storage for medications that need refrigeration.

- We recommend that you call ahead to find out if you can bring your medications and medical supplies.

- In addition, let them know if you will be using medical equipment that requires an electrical outlet.

- During our planning for a natural emergency, we will contact you and deliver, if possible, at least one week's worth of medication and supplies.

- Bring all your medications and supplies with you to the shelter.

Reaching us during an emergency:

- In the case of an emergency, please call our main phone number (fill number).

- If the office is closed due to an emergency, our on-call services are always available.

- If you have no way to call our number, you can try to reach us by having someone you know call us from his or her cellular phone.

- Should a life-threatening medical emergency arise, it is suggested the patient or caregiver contact their local emergency services number for assistance (usually 911).

Appendix E - Client/Patient Bill of Rights & Responsibilities

Client/Patient has the right to:

- Receive reasonable coordination and continuity of services from the referring agency for home medical equipment services.

- Receive a timely response from MPA Medical when services/care are needed or requested.

- Be fully informed in advance about service/care to be provided, including the disciplines that furnish care and the frequency of visits, as well as any modifications to the Plan of Care.

- Participate in the development and periodic revision of the Plan of Service or the Plan of Care.

- Informed consent and refusal of services, care, or treatment after the consequences of refusing services, care, or treatment are fully presented.

- Be informed in advance of the charges, including payment for service or care expected from third parties and any charges for which the client/patient will be responsible.

- Have one’s property and person treated with respect, consideration, and recognition of client/patient dignity and individuality.

- Be able to identify visiting staff members through proper identification.

- Voice grievances/complaints regarding treatment of care or lack of respect of property, or recommend changes in policy, staff, or service/care without restraint, interference, coercion, discrimination, or reprisal.

- Have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated.

- Choose a health care provider and have access to information regarding the provider’s work history and training.

- Confidentiality and privacy of all information contained in the client/patient record and of Protected Health Information.

- Receive appropriate service/care without discrimination in accordance with physician orders.

- Be informed of any financial benefits when referred to an organization.

- Be informed in advance of care/service being provided and their financial responsibility.

- Be fully informed of one’s responsibilities and MPA Medical’s policies regarding patient responsibilities.

- Be informed of client/patient rights under state law to formulate advance care directives.

- Be informed of anticipated outcomes of service or care and of any barriers in outcome achievement.

- Be informed of MPA Medical’s on-call service.

- Be informed of MPA Medical’s patient satisfaction survey process.

- Be informed of supervisory accessibility and availability.

- Fair treatment, regardless of race, ethnicity, creed, religious belief, sexual orientation, gender, age, health status, or source of payment for care.

- Be advised on MPA Medical’s policies and procedures regarding the disclosure of clinical records, clinical guidelines, and management of care.

- Be advised of MPA Medical’s procedures for discharge.

- Report fraud, waste, or abuse.

- Be notified within 10 days if MPA Medical’s license is revoked, suspended, canceled, annulled, withdrawn, recalled, or amended.

- Know of their rights and responsibilities in the treatment process (and the laws that relate to them), and to make recommendations regarding the organization's rights and responsibilities policy.

- Be informed about advocacy and community groups and prevention services.

- Access care easily and in a timely fashion.

- Candid discussion about all their treatment choices, regardless of cost or coverage by their benefit plan.

- The delivery of services in a culturally competent manner.

- Receive information about the scope of services that the organization will provide and specific limitations on those services.

- Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of an unknown source, and misappropriation of client/patient property.

Client/Patient has the responsibility to:

- Use rental equipment with reasonable care, avoid alterations or modifications, and return it in good condition (normal wear and tear excepted).

- Promptly report to MPA Medical any malfunctions or defects in rental equipment so that repair/replacement can be arranged.

- Provide MPA Medical access to all rental equipment for repair/replacement, maintenance, and/or pick-up of the equipment.

- Use the equipment for the purposes so indicated and in compliance with the physician’s prescription.

- Keep the equipment in their possession and at the address to which it was delivered unless otherwise authorized by MPA Medical.

- Notify MPA Medical of any hospitalization, change in customer insurance, address, telephone number, physician, or when the medical need for the rental equipment no longer exists.

- Request payment of authorized Medicare, Medicaid, or other private insurance benefits to be paid directly to MPA Medical for any services furnished by MPA Medical.

- Accept all financial responsibility for home medical equipment furnished by MPA Medical.

- Pay for the replacement cost of any equipment damaged, destroyed, or lost due to misuse, abuse, or neglect.

- Not modify the rental equipment without the prior consent of MPA Medical.

- Agree that any authorized modification shall belong to the titleholder of the equipment unless equipment is purchased and paid for in full.

- Recognize that title to the rental equipment and all parts shall remain with MPA Medical at all times unless equipment is purchased and paid for in full.

- Understand that MPA Medical shall not insure or be responsible for any personal injury or property damage related to the equipment; including that caused by use or improper functioning of the equipment; the act or omission of any third party, or by any criminal act or activity, war, riot, insurrection, fire, or act of God.

- Acknowledge that MPA Medical retains the right to refuse delivery of service to any client at any time.

- Understand that any legal fees resulting from a disagreement between the parties shall be borne by the unsuccessful party in any legal action taken.

- Provide information needed by providers to offer the best possible care and ask questions about their care.

- Treat those giving care with dignity and respect and avoid actions that could harm others.

- Understand and help develop and follow the agreed-upon treatment plans for care, including the agreed-upon medication plan, and notify the provider when the treatment plan no longer works.

- Keep appointments and inform providers as soon as possible if they need to cancel visits.

- Notify the provider of any changes in contact information (name, address, phone, etc.) and insurance coverage.

- Inform the provider about medication changes, including medications given by others.

- Notify the provider of problems with paying fees.