PATIENT AGREEMENT

patient financial responsibility

As directed by your physician’s prescription, ēlizur, Advanced Integrated Medical (AIM), and whenrequired their associated partners, “DME Provider” are providing you with musculoskeletal product(s). Please note that this “DME Provider” functions as a separate organization from your referral source. You have the right to choose any qualified vendor to provide the prescribed product, and with your signature, you acknowledge that you have freely chosen this “DME Provider” as your provider for this product(s).

I received the billing guide, return policy, equipment warranty, Medicare DMEPOS supplier standards, industry accreditation – quality assurance information, statement of financial responsibility, patient responsibilities, patient freedom of provider statement, patient bill of rights, fall prevention
information, and notice of privacy practices.

I agree to allow “DME Provider” to use my Protected Health Information “PHI” for Health Care Operations including payment of claims, obtaining information from my designated health care provider, and for quality assurance/improvement. If I choose not to allow “DME Provider” to release my “PHI”, I will be responsible for payment of all products and services I have received. This notice will terminate when my account balance with this “DME Provider” is at zero dollars for more than 60 days.

MEDICARE ASSIGNMENT FOR COVERED SERVICES

I certify that the information given by me in applying for payment is correct. I request that payment of authorized benefits be made in my behalf to this “DME Provider”.

RETURN POLICY – WITHIN 3 BUSINESS DAYS

Non-custom products can be returned in like new condition within 3 business days of service. Note custom products CANNOT be returned. Contact ēlizur at 877-354-9870 to initiate a return. For further information on our return policy please see ‘Notice of Supplier Standards’ section.

ASSIGNMENT OF INSURANCE BENEFITS/RELEASE OF INFORMATION

I hereby authorize payment for medical service and/or services directly to the provider. I represent that I have insurance coverage and do hereby authorize this “DME Provider” to release and obtain all information necessary to secure payment of said benefits. If my insurance fails to pay this “DME Provider” in full, I agree to pay all unpaid balances. If litigation is instituted to collect any unpaid balance, I agree to also pay all costs, including attorney’s fees incurred by this “DME Provider”.

BILLING GUIDE

billing explained

As directed by your physician’s prescription, ēlizur has provided you with musculoskeletal products and services. By signing our Patient Agreement, you have authorized ēlizur, or an authorized Partner Company, to submit a claim to your insurance company for the services and equipment we provide. This insurance claim, submitted on your behalf, is separate from your physician’s claim. You have a choice in your medical care. If you wish, you may have another company fill your prescriptions.

As the recipient of products and services, it is your responsibility to pay any amount not covered by your insurance company. Even for covered services, your insurance plan may require you to pay for a portion of the bill. If ēlizur is not a participating provider with your insurance, you will be responsible for the full payment of the bill. We accept cash, check, and all major credit cards. Note: Due to the nature of health care, you will likely receive any invoice after the 3 business day window for returns.

If your diagnosis is related to a Worker’s Compensation or Auto claim, please let us know to
ensure proper billing.

If you have any questions regarding billing or would like more information on our products, please call the ēlizur Patient Concierge team at 877-354-9870.

terms defined

PATIENT RESPONSIBILITY The amount the patient has to pay. This cost generally starts with the insurer’s “approved” rate for the claim, then divides the cost between the patient and the insurer as outlined in the patient’s EOB (Explanation of Benefits).

DEDUCTIBLE The amount the patient must pay before the health insurer pays its share for some or all services.

CO-PAY A specified dollar amount that is determined by a patient’s insurance company and paid out-of-pocket by the patient towards a covered service.

CO-INSURANCE The percentage of costs for a covered health care service that the patient pays. Sometimes the co-insurance is above and beyond the fixed co-pays.

BILLED/UCR The customary and reasonable amount invoiced to an insurance company /patient to request reimbursement for health care services and/or products received. The Billed/UCR amount is typically higher than the “approved” rate.

APPROVED The portion of the “billed/UCR” amount that the insurer finds acceptable to reimburse.The difference between the “billed/UCR” and “approved” amounts are adjusted off on the billing statement.

NOTICE OF OUR SUPPLIER STANDARDS

return policy – within 3 business days

Non-custom products can be returned in like new condition within 3 business days of service. Within 3 business days of receiving the product, the customer must notify this “DME Provider’s” Patient Concierge team at 877.354.9870 to make arrangements for any non-custom product return. Note custom products cannot be returned.

  1. A product is NOT returnable if:
    • The item has been visibly worn, or is soiled.
    • The item has been personalized with a patient’s name or other markings.
    • The packaging has been destroyed or is missing.
    • Alterations or adjustments were made by anyone other than this “DME Provider”
      (and may invalidate the warranty).

equipment warranty

  1. In the event that this “DME Provider” has mistakenly provided the incorrect product or size, the following steps will be taken:
    • Within 48 hours of receiving the incorrect product the customer must notify this
      “DME Provider’s” Patient Concierge team at 877.354.9870.
    • The Patient Concierge team will issue a call tag to pick up the product.
    • If applicable the correct item will be shipped to the customer.
    • The customer account will be adjusted to reflect the return/exchange.
    • If the product was delivered by the “DME Provider’s” staff, the return/exchange may be in person.
  2. We warranty all “off the shelf” products according to manufacturer’s warranties. Please see the information included in the manufacturers’ packaging literature. All custom products are
    warranted for 90 days from the date of delivery, providing that they are properly utilized and cared for in accordance with this “DME Provider” delivery instructions.
  3. Warranty is defined as: Replacement of the original product (with the same or similar product at the sole discretion of this “DME Provider”), or repair of the product to “like new” condition at no cost to the consumer.

Medicare DMEPOS supplier standards

The product(s) and/or service(s) provided to you by ēlizur, AIM, and when required their associated partners (“DME Provider”), 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 http://www.ecfr.gov/cgi-bin/text-idx. Upon request, we will furnish you with a written copy of the standards.

Note: This list is an abbreviated version of the application certification standards, that every Medicare DMEPOS supplier must meet.

  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. An authorized individual (one whose signature is binding) must sign the enrollment application for billing privileges.
  4. A supplier must fill orders from its own inventory or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is
    currently excluded from the Medicare program, any State health care programs or from any other federal procurement or non-procurement 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 and must instruct beneficiaries on 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 directly or through a service contract with another company 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
    implementing 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 of 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 C.F.R. 424.57(c).
  27. A supplier must obtain oxygen from a state-licensed oxygen provider.
  28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 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.

industry accreditation – quality assurance

ēlizur is proud to be accredited through The Joint Commission and ABC – American Board for Certification in Orthotics and Prosthetics. The stringent standards set by these bodies translates to patients and health care professionals receiving the highest level of care.

Founded in 1951, The Joint Commission seeks to continuously improve the safety and quality of care provided to the public. They have succeeded in their quest through the provision of health care accreditation and related services that support performance improvement in health care organizations. An independent, not-for-profit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care.

For more information on ēlizur’s accreditation please visit http://www.qualitycheck.org/

If you have a patient safety event, or concern regarding the care that ēlizur provided to you, you can contact The Joint Commission online at https://www.jointcommission.org/ or by phone at 630-792-5800.

ABC has been accrediting orthotic, prosthetic and pedorthic patient care organizations since 1948 and still maintains the highest standards in the profession. They are a Medicare Deemed Authority for all aspects of Medicare Part B DMEPOS care and service.

patient satisfaction survey

We appreciate all feedback. Please rate your experience at elizur.com/survey

NOTICE OF YOUR CONSUMER RESPONSIBILITIES

statement of financial responsibility

Leading providers of off-the-shelf and custom orthopaedic bracing, ēlizur, AIM, and when required their associated partners (“DME Provider”), offers a wide range of products that may be covered by your insurance. “DME Provider” is a participating provider with Medicare, select Medicaid plans, and
thousands of Managed Care plans. Our highly trained product and insurance specialists are available to work with your insurance provider and bill them for products on your behalf.

As the patient/consumer, it is your responsibility to provide us with proper and updated insurance information. You are also responsible for all unpaid balances. “DME Provider” reserves the right to collect all deductibles and co-payments from you. If you have supplemental insurance that pays for your co-payment and “DME Provider” has a contract with that company, “DME Provider” will submit a claim on your behalf. When requesting a product, if you do not have proof of insurance, you will be asked to provide “DME Provider” with a credit card to secure payment until the appropriate insurance information is provided.

“DME PROVIDER” ACCEPTS THE FOLLOWING FORMS OF PAYMENT

  • Personal Check
  • Electronic Check
  • Major Credit Cards (Visa, MasterCard)
  • Health Savings Account (HSA) Cards (Must Be Affiliated with the Aforementioned Credit Cards)

If you cannot meet any of the above requirements or have any questions regarding “DME Provider’s” billing services, please call 877.354.9870.

patient responsibilities

  1. Give accurate and pertinent complete health information concerning your past illnesses, hospitalization, medications, allergies, and any other items.
  2. Assist in developing and maintaining a safe environment at your home.
  3. Inform ēlizur when you will not be able to keep an appointment for a scheduled visit.
  4. Participate in the development and update of your orthotic plan of service when appropriate.
  5. Adhere to your newly developed or updated orthotics or prosthetics plan of service when appropriate.
  6. Request further information concerning anything you do not understand.
  7. Contact your doctor & elizur whenever you notice any unusual feelings or sensations during your plan of service.
  8. Contact your doctor whenever you notice any change in your condition.
  9. Contact elizur whenever your insurance company or plan changes.
  10. Contact elizur whenever you have any equipment problem.
  11. Contact elizur whenever you have received a change in your orthotic, prosthetic, or DME prescription.
  12. Give information regarding concerns and problems you may have to an elizur staff member.
  13. Contact elizur with any change of address.
  14. If you are renting any equipment from elizur, please notify us if you are hospitalized or require a stay in a skilled nursing facility for any period during your plan of service.
  15. If you are renting any equipment from elizur, please notify us if you are diagnosed with an infectious disease during the time you are receiving services from us, except where exempted by law.

fall prevention: things you can do!

  1. Begin a regular exercise program.
    • Exercise is one of the most important ways to lower your chances of falling. It makes you stronger and helps you feel better. Exercises that improve balance and coordination are the most helpful.
    • Lack of exercise leads to weakness and increases your chances of falling. Ask your doctor or health care provider about the best type of exercise program for you.
  2. Have your health care provider review your medications.
    • Have your doctor or pharmacist review all the medications you take, even over-the-counter medicines. As you get older, the way medicines work in your body can change. Some medicines, or combinations of medicines, can make you sleepy or dizzy and can cause you to fall.
  3. Have your vision checked.
    • Have your eyes checked by an eye doctor at least once a year. You may be wearing the wrong glasses or have a condition like glaucoma or cataracts that limits your vision. Poor vision can increase your chances of falling.
  4. Make your home safer; about half of all falls happen at home.
    • Remove things you can trip over (like papers, books, clothes, cords, and shoes) from steps and walking surfaces.
    • Remove small throw rugs or use double-sided tape to keep the rugs from slipping.
    • Improve the lighting in your home. As you get older, you need brighter lights to see well. Hang light-weight curtains or shades to reduce glare.
    • Keep items you use often in cabinets you can easily reach. Use a step stool that is steady with a hand bar.
    • Have grab bars put in next to your toilet and in the tub or shower. Use non-slip mats in the bathtub and on shower floors.
    • Have handrails and lights in all staircases. Replace old carpet on stairs. Fix loose or uneven steps. Paint contrasting color on top edge of stairs.
    • Wear shoes both inside and outside the house. Avoid going barefoot or wearing slippers.
    • Consider the weather’s effect on walking surfaces.
    • Consider using an alarm device to call for help. Keep large print emergency numbers near the phone.

NOTICE OF CONSUMER RIGHTS

patient freedom of provider statement

I have been referred to ēlizur, AIM, and when required their associated partners (“DME Provider”), for medical products. I understand that “DME Provider” is a separate organization from my referral source. I further understand that “DME Provider” will bill me, or my insurance company, separately.

I understand my rights and responsibilities in this referral process and transaction. I also understand that I have a right to choose any qualified vendor to provide me with my physician’s prescribed bracing protocol. I have freely chosen “DME Provider” as my provider for the prescribed product.

patient bill of rights

Customer/patient rights and responsibilities includes, but is not limited to the following.

  1. To be notified in writing of your rights and responsibilities before treatment has begun.
  2. To dignity and respect of privacy and personal property.
  3. For your family or guardian to exercise your rights when you are judged incompetent.
  4. To have relationships with home care providers that are based on honesty and ethical standards of conduct.
  5. To be informed of the procedure you can follow to lodge complaints with the home care provider about the care that is, or fails to be furnished, and regarding a lack of respect for property.
  6. To know about the disposition of such complaint.
  7. To voice your grievances without fear of discrimination or reprisal for having done so.
  8. To be advised of the agency’s address, telephone number, and hours of operation.
  9. To request information about your diagnosis, prognosis, and treatment, including alternatives to care and risks involved, in terms that you and your family can easily understand so that you/they can give informed consent.
  10. To receive the state’s home health “hot line” phone number if present in your state and/or The Joint Commission phone number.
  11. To be notified in writing of the care that is to be furnished, the types (disciplines) of the care givers who will furnish the care and the frequency of the visits that are proposed to be furnished.
  12. To be advised of any change in the plan of care before the change is made
  13. To participate in planning your care and to participate in any changes.
  14. To receive appropriate instruction and education regarding plan of care.
  15. To refuse service(s) or request a change in care giver without fear of reprisal or discrimination and to be informed of possible health consequences of this action.
  16. To be referred elsewhere if you are denied service(s) for any reason.
  17. To confidentiality with regard to information about your health, social, and financial circumstances and about what takes place in your home.
  18. To expect the home care provider to release information only as required by law or authorized by you.
  19. To be informed of the extent to which payment may be expected from Medicare, Medicaid, or any other payer and of the charges for which you will be liable.
  20. To be informed of the agency policies and charges that will not be covered by Medicare, Medicaid, or any other payer and the charges for which you will be liable.
  21. To receive the above information orally and in writing when the home care provider becomes aware of any changes in charges.
  22. To have access, upon request, to all bills for service(s) you have received regardless of whether they are paid out-of-pocket or by another party.
  23. To be admitted by a home care provider only if it has the resources needed to provide the care safely and at the required level of intensity, as determined by a professional assessment; however, a provider with less than optimal resources may nevertheless admit you if a more appropriate provider is not available but only after fully informing you of its limitations and the lack of suitable alternative arrangements.
  24. To be told what to do in the case of emergency.
  25. That all medically related home care is provided in accordance with physician orders and that a plan of care specifies the service(s) to be provided and their frequency and duration.
  26. To an appropriate assessment and management of your pain (if applicable).