Drop Ship Packet 2009

Dear Valued Customer, Thank you for choosing A Caring Kind of Place Medical Supplies and Equipment for your healthcare needs. Enclosed are several forms we are required to give to you. Please keep all of these for your records. The only form we need back is the first page the (“Patient Consent form”). Please sign this form and return to us in the self addressed stamped envelope. Our company prides itself in supplying quality products and taking care of our customers. I am sending you a satisfaction survey (second page). If you could give us any feedback it would be greatly appreciated. Please call our office if you have any questions and please let us know if we can be of any future service to you. We would like to be your resource for your medical supply or equipment needs.

Sincerely, A Caring kind of Place Medical Supplies and Equipment

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14219 Walsingham Rd. •Largo, FL 33774•Ste L• Ph: 866-927-8480 Fx: 727-595-8447

Privacy Notice (as required by HIPPA) ALL CUSTOMER HEALTHCARE INFORMATION WILL BE KEPT PRIVATE A Caring Kind Of Place Medical Supplies & Equipment, Inc. may be required to use information in the following ways: -Treatment. We may utilize or possibly disclose your health information to your healthcare provider only in order to assist in our supplying of medical products and/or equipment and in the treatment of your condition. -Payment. We may be required to disclose your health information in order to collect payment from third parties for services rendered or supplies provided. -Delivery Reminders. A Caring Kind Of Place Medical Supplies & Equipment, Inc. may need to use your personal information in order to be able to contact you. -Release of Information to Family/Friends. We may need to provide information to an individual if you are being cared for by a family member or friend. -Disclosures Required by Law. Our organization will disclose health information when we are required by federal state or local law. -Public Health Risks, Health Oversight Activities, Workers Compensation. -Lawsuits Law Enforcement, Threats to Health and Safety, Military, National Security. Your Rights Regarding Your Identifiable Health Information: -Confidential Communications. You have the right to request that our organization communicate with you about you and your health. In addition you may request that this communication take place in a confidential environment. This request must be given in writing. -Requesting Restriction. You may request a restriction in the use or disclosure of your personal health information to individuals involved in our dispensing of medical supplies. This request must be given to us in written form. -Inspection and Copies. You have the right to request a copy of the identifiable health information that we may utilize for your care. This request must be provided in writing. - Amendment. You may request that we amend your information if you think that we have incorrect information in our records. This request must be provided in writing. -Accounting of Disclosures. All of our patients have the right to request a list of any disclosures our organization makes of your personal information (such as to your medical doctor or to our technician). -You have a right to a copy of this notice. -You have the right to file a complaint if you believe your privacy rights have been violated.

EQUIPMENT WARRANTY INFORMATION Every product sold or rented by our company carries a 1-year manufacturer’s warranty. A Caring Kind of Place Medical Supplies & Equipment, Inc. will notify all Medicare beneficiaries of the warranty coverage, and we will honor all warranties under applicable law. A Caring Kind of Place Medical Supplies & Equipment, Inc. will repair or replace, free of charge, Medicare-covered equipment that is under warranty. In addition, an owner’s manual with warranty information will be provided to beneficiaries for all durable medical equipment where this manual is available.

RETURN POLICY A Caring Kind of Place Medical Supplies & Equipment, Inc. will accept returns of substandard or unsuitable items at no charge. If you are unhappy with the item(s) you have received, please contact us directly.

I have been instructed and understand the warranty coverage and return policy on the product I have received

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14219 Walsingham Rd. •Largo, FL 33774•Ste L• Ph: 866-927-8480 Fx: 727-595-8447

A Caring Kind of Place Medical Supplies and equipment, Inc. wants you to be satisfied with the products and services that you receive from our company. If, at any time, you are concerned, have a problem, or wish to voice a grievance you may do so without fear of reprisal. We encourage you to let us know when you are not satisfied. You may call our manager at 866-927-8480. The Manager will investigate your grievance, within 72 hours of receipt and make every reasonable effort to resolve the concern to our mutual satisfaction. We encourage patients to voice their concerns and allow our staff the opportunity to resolve any problems or grievances that may arise. We look forward to successfully meeting your needs. Best Regards,

WM C. Koenig CEO ______________________________________________________________________________________________

14219 Walsingham Rd. •Largo, FL 33774•Ste L• Ph: 866-927-8480 Fx: 727-595-8447

Patient Bill of Rights Your Patient Rights and Responsibilities… Patients who receive home medical equipment services from our company are entitled to be notified in writing of their rights and obligations before services begin and to exercise those rights. Patients of A Caring Kind Of Place Medical Supplies & Equipment, Inc. have the Right to:             

receive a timely response from our company to your request for equipment and service; be informed of our policies, procedures; be informed of any charges for services, including eligibility for third party reimbursement; voice a grievance with our company by calling 866-927-8480 or you may call the OIG hotline without fear of restraint or reprisal in the services you are receiving, TO REPORT ABUSE, NEGLECT, OR EXPLOITATION, PLEASE CALL 1-800-252-5400. the appropriate quality of home medical equipment and services without regard for race, creed, sex, national origin, sexual preference, handicap or age; respectful and courteous treatment by all members of our company; know the names and the preparation of those who provide service to you on our behalf; complete accurate information concerning the equipment, services, and supplies provided and any potential risks, in a language you can reasonably be expected to understand; receive the necessary information so that you may make an informed consent; participation in the development of a plan of care to meet your health care needs with periodic updates and revisions as appropriate; have all the information regarding your equipment and services treated confidentially; receive information about anticipated transfer or discharge from our services; review your clinical record upon your written request.

. Patients of A Caring Kind Of Place Medical Supplies & Equipment, Inc. have the Responsibility to:  Give accurate and complete information pertinent to your equipment and supply needs;  Assist in providing and maintaining a safe environment;  Notify our office if the scheduled visit needs to be changed;  Notify our office if the equipment or supplies you receive malfunction or become unusable;  Adhere to the manufacturer’s guidelines for the recommended use of the medical equipment provided to you;  Notify our company of any changes in your physician or other provider that will affect the services you receive from our company;  Request information concerning anything pertaining to your medical equipment / supplies that you don’t understand;  Notify us of any concerns, problems or dissatisfaction with the services we provide to you;  Notify us of any change in your insurance plan or Payor source. ______________________________________________________________________________________________

14219 Walsingham Rd. •Largo, FL 33774•Ste L• Ph: 866-927-8480 Fx: 727-595-8447

PATIENT SATISFACTION SURVEY To help us in our commitment to quality assurance, please complete the following survey and mail it to the address located on the bottom of this page. PATIENT NAME: ________________________________________________________ DATE OF DELIVERY: ____________________________________________________ ITEMS DELIVERED: _____________________________________________________ DELIVERY TECHNICIAN: ________________________________________________ Were you properly instructed on the use of the supplies/equipment? ____Yes ____No Was your delivery technician friendly? ____Yes ____No Were all of your questions answered? ____Yes ____No Did the delivery technician go over all of your paperwork? ____Yes ____No Were you given warranty/repair information? ____Yes ____No Was our return policy explained to you? ____Yes ____No Were you told how to voice a complaint to us? ____Yes ____No Was financial responsibility discussed with you? ____Yes ____No Did the delivery technician go over home safety of the equipment? ____Yes ____No How would you rate Medicare’s rules regarding home medical equipment and the impact these rules have on your access to the products and services you believe your require? ____Excellent ____Good ____Fair ____Poor How would you rate your overall satisfaction with the delivery experience on a scale of 1-10? (10 being exceptional and 1 being poor) 1 2 3 4 5 6 7 8 9 10 Notes/Comments: ________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Signature: ________________________________________

Date: _____________

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14219 Walsingham Rd. •Largo, FL 33774•Ste L• Ph: 866-927-8480 Fx: 727-595-8447

□Circled if product will be shipped via mail

Patient Consent form Patient name: ____________________________________________

I certify the information given by me in applying under title XVII of the Social Security act is correct. I authorize any holder of medical or other information about me to release it to the Center for Medicare and Medicaid Services or its agents any information needed for this or a related Medicare claim. I request that the payment of authorized benefits be made on my behalf. I assign benefits payable for services of A Caring Kind of Place Medical Supplies & Equipment, inc. to be paid to A Caring Kind of Place Medical Supplies & Equipment, Inc. or authorize A Caring Kind of Place Medical Supplies & Equipment, Inc. to submit a claim to Medicare for payment for me. Assignment of Medicare claims does not mean that Medicare pays your entire bill. Patient’s responsibility on assigned Medicare claims includes payment of: --Annual Medicare deductible (currently $135.00) -- 20% co-insurance on approved services --Non-covered services --Services rendered under a waiver of liability, approved, but not paid by Medicare I hereby acknowledge that I have been given a copy of the “Privacy Notice”. This notice describes how health information may be used and disclosed and how a patient can get access to their health information. I have been advised by A Caring kind of Place Medical Supplies & Equipment, Inc. to read this document and to forward any questions to their Compliance Officer at the above number. I certify that I have been instructed and understand the complaint and warranty policy as well as the customer instruction for use. . I consent to receiving information on the products supplied. I consent to receiving the 26 supplier Standards. I consent to receiving the Patient Bill of Rights. I consent to receiving notification of how to voice a complaint. I consent to receiving Equipment Warranty and Return Policy. I consent to receiving the Patient Grievance Letter. I consent to receiving the Patient Satisfaction Survey. I authorize any holder of medical information about me to be released to A caring Kind of Place Medical Supplies & Equipment, Inc. or my insurance carrier any information necessary to determine benefits and payment. I permit a copy of this authorization to be used in place of the original.

Signature of Patient: __________________________________________ Date: ___________________

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14219 Walsingham Rd. •Largo, FL 33774•Ste L• Ph: 866-927-8480 Fx: 727-595-8447