PATIENT NOTICES AND ACKNOWLEDGMENTS
WARRANTY: Graymont Medical will honor all applicable factory warranties for durable medical equipment purchases and will repair or replace, free-of-charge, Medicare-covered equipment that proves defective while under warranty. An owner’s manual with warranty information will be provided to beneficiaries for all durable medical equipment where this manual is available. The length of warranty depends on the product and the manufacturer. Due to sanitary restrictions, any items that are not rentals cannot be returned unless proven defective under warranty and will be replaced with a like item only.
RETURNS: Returns are accepted under the following conditions: • RENTAL ITEMS: ◦ Must be returned by the scheduled return/ pick-up date unless use has been extended either by physician order or additional payment (if applicable). ◦ May be returned early if your physician advises to stop use of the item before your original prescribed length of use. ◦ That prove defective or malfunction will be serviced and/or switched out when notified of the issue • Non-rental items can only be returned or replaced if they prove to be defective while still under warranty. • In order to return an item, you must call us and request a Return Authorization (RA) number. After receiving the RA number, the product must be shipped within 10 days. • Note: This returns policy also applies to orders canceled after shipment.
RIGHT TO RENT OR PURCHASE FOR MEDICARE BENEFICIARIES: I understand that I have the right to rent or purchase items that Medicare considers inexpensive or routinely purchased durable medical equipment. I have been notified that it is the policy of Graymont Medical to offer inexpensive durable medical equipment for sale only. I understand that if I am interested in renting durable medical equipment that is considered inexpensive, Graymont Medical will provide contact information for an alternate supplier.
MEDICARE DMEPOS SUPPLIER STANDARDS: The products and/or services provided to you by Graymont 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/media/187396. Upon request, we will furnish you a written copy of the standards.
PATIENT RIGHTS: You have the right to be treated with respect, consideration and dignity. You have the right to high-quality medical care delivered in a safe, timely, efficient and cost-effective manner and the right to be assured that the expected results can be reasonably anticipated. You have the right to privacy to the extent possible. You have the right to have your disclosures and records treated confidentially and, except when required by law, those disclosures and records will not be released without your approval. You have the right to be provided, to the degree known, complete information concerning your diagnosis, evaluation, treatment and prognosis. You have the right to copies of your medical records at a nominal cost and, if you request it, those records will be transferred to another practitioner in a timely manner. You have the right to know all of your rights as outlined above. You have the right to know the conduct expected of you and the consequences of failure to comply with these expectations. You have the right to know the items and services available. You have the right to know the provisions for after-hours and emergency. You have the right to know whether or not your providers are insured. You have the right to know how to go about expressing suggestions and the policies regarding grievance and external appeals in the event that you are dissatisfied with your treatment. You have the right to know the name of your provider. You have the right to know what fees are expected and what payment policies are. You have the right to know what your provider’s credentials are. You have the right to change providers.
PATIENT RESPONSIBILITIES: You have the responsibility to accurately and completely provide all clinical personnel with the health information they need. You have the responsibility to follow the directions regarding the equipment. You have the responsibility to inform the tech or physician if you do not understand any directions or do not understand the course of treatment planned for you. You have the responsibility to timely pay all medical bills which are not in dispute and to forward to us any monies you receive from any insurance company for our services.
ACKNOWLEDGEMENT OF FALL PREVENTION MEASURES: Patient acknowledges that he/she has been instructed on potential fall hazards and general prevention as stated below:
INDOOR AREAS
FLOORS• Make sure your path is clear and stable at all times. You should be able to move freely between rooms without obstructions, and should avoid slippery, unsteady surfaces while using the equipment. • Consider your space for any mobility equipment that may be provided (i.e.wheelchairs,kneerollers,walkers, crutches,etc.). If using a device that is larger than or extends beyond you, clear a path large enough to allow you to move and maneuver, unobstructed, while using that device. • Remove or move out of the way any furniture, rugs, cords or wires, shoes, blankets, boxes, papers, toys, towels, or other objects that are in your walking or maneuvering path.
STAIRS & STEPS • Cover slippery stairs with a non-slip surface safe for floors. Check for and repair any uneven, broken, or loose steps. • Always use handrails when moving up/down stairs or steps. Install or repair any that are missing, loose, or broken. • Avoid using stairs or steps, when possible, if you are not able to safely move up and down them with your device(s).
LIGHTING • Make sure you have a well-lit path at all times. Replace or have someone help you replace any lightbulbs that are out. • Check that light switches or lamps are easy to reach near your couch, chair, bed or other resting area. If not easily accessible; move a lamp closer, add a night-light, or have a flashlight or other mobile light accessible.
WET SURFACES • If your tub or shower is slippery; put down a non-slip rubber mat, self-stickstrips, and/or a waterproof chair or bench. • Make sure you have the support needed to get in/out of the tub or to/from the toilet. Install handrails and/or add a chair or other stable platform you can use to assist yourself while getting in/out. • Be sure to have a non-slip rug on the floor of the bathroom, kitchen, laundry room, and/or any other room where the floor may be slippery when wet. Dry any surfaces that may be wet before walking or using a mobility device on them.
EATING/DINING AREAS • Place all necessary food and cooking utensils on lower shelves orcabinets so you do not have to climb, stretch, or overreach to access them. If you must use a step stool, be sure to have one with a bar support to hold on to.
OUTDOOR AREAS • Look out for road or pathway hazards such as rocks,tree branches,raised sidewalks, curbs, potholes, other debris, etc. Find an easier or cleared path to take before walking or using mobility equipment. Never try to “roll over” these objects. • If there’s snow, ice, or water accumulation on roadways/sidewalks/other terrain, that would make the surface slippery or unstable, do not try to use any mobility assistance devices on these surfaces. Always find a safer, more stable path to take. • Check equipment before and after use to make sure it’s functioning properly. If the item(s)seem unstable – brakes aren’t working, wheels or crutches are wobbly,straps(if applicable) aren’t securing; contact us for assistance before using them.
RISK OF LOSS: The provider is not responsible for loss or damage to property, material or equipment belonging to the patient, his/her agents, employees, guests, suppliers or anyone directly or indirectly affiliated with you while said material property, or equipment, is in his/her care, custody and/or control.
RECALL NOTICE: The provider may recall any or all equipment provided upon five (5) business days with written notice to patient.
ACKNOWLEDGMENT OF USE INSTRUCTIONS: Patient acknowledges that he/she has been instructed on how to use the equipment and takes full responsibility for the proper use and care of the equipment.
CUSTOMER COMPLAINTS: You have the right to freely voice grievances and recommend changes in care or services without fear of reprisal or unreasonable interruption of services. Service, equipment and billing complaints will be communicated to Graymont Medical’s management. These complaints will be documented in the complaint log, and will include the patient’s name, address, telephone number, health insurance claim number, summary of the complaint, the date it was received, the name of the person receiving the complaint and a summary of actions taken to resolve the complaint. All complaints will be handled in a professional manner. All logged complaints will be investigated, acted upon and responded to in writing or by telephone by the compliance officer within 24-48 hours after the receipt of the complaint. If there is not a satisfactory resolution of the complaint, the next level of management will be notified progressively, up to the owner of the company. The patient will be informed of this complaint resolution protocol at the time of set-up of service. If you feel you have not received the quality of service you expected, please call Graymont Medical at (312) 291-9305 to state your complaint.
REPORTING INJURIES RELATED TO EQUIPMENT RECEIVED: If you feel that you have sustained an injury as a result to equipment or supplies that we provided to you, please contact us at (312) 291-9305 as soon as you can. We will need to know the date and time when the injury occurred, a description of the injury, a description of why you think it occurred, whether or not you received any medical treatment as a result of the injury and any other pertinent details. We will replace any defective equipment and will ask that you return the defective unit to us so that we may follow manufacturer reporting guidelines.
TO REPORT ABUSE, NEGLECT OR EXPLOITATION: According to State law, you and members of your family have the right to report abuse, neglect or exploitation to their state agency.
TO REPORT MEDICAID FRAUD: To report suspected Medicaid fraud, you can call the OIG National Fraud Hotline at (800) 447-8477. Medicaid Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or herself or some other person. It includes any act that constitutes fraud under applicable federal or state law as it relates to Medicaid. The Office of the Inspector General at the Agency for Health Care Administration accepts complaints regarding suspected fraud and abuse.
PREPARING FOR WEATHER EMERGENCIES: Graymont Medical wants all of our customers to be prepared for any weather that may interrupt delivery of your medical equipment or supplies. We pay close attention to the weather encourage you to do the same. In case of any weather emergencies that may affect the ability of Graymont Medical to operate safely, our offices may close for one or more days. If you anticipate being affected by a weather emergency that may interrupt your regular delivery, please call our office at (312) 291-9305 and ask to expedite your delivery. If you relocate either temporarily or permanently as a result of a weather emergency, please provide us with your new address as soon as possible so that we may ship your supplies to the correct location. Please remember that you may email update information to us at customerservice@graymontmedical.com. Once the weather emergency has passed, the Graymont Medical will resume normal operations. In the event that you are unexpectedly affected by a weather emergency and need emergency replacement of equipment or supplies, please contact us at (312) 291-9305 and we will ship the necessary items to you as soon as possible.
