Schreiber
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_______________:Date
INVOICE
Bill to:
Advance Medical Inc
PO Box Box 340431 Tampa, FL 33694
Item / Device: _________________
PATIENT NAME ADMINISTRATION Initial ________$ 50.00 Completed, reviewed and explained in full the agreement for the electro-therapy modalities and supplies, between patient and invoiced company. Explained the patient’s rights and obligations. Served as a focal point for distribution of the products furnished. Reviewed and/or made available to the patient the Notice of Privacy Practices.
INSTRUCTIONAL USAGE Initial ________$ 50.00 Instructed the above patient on the proper use the equipment. Explained why the item was prescribed and what the patient should expect from its effectiveness. Reviewed all warning and contraindications of the item.
TOTAL:
$100.00
The equipment prescribed to the above patient was based solely on medical necessity. I am under no obligation to prescribe any equipment from the invoiced company. If necessary, I agree to furnish any supporting documentation (examination findings, office notes, progress notes, etc.) in order to verify the necessity, administration and monitoring of the prescribed item.
___________________________________________________ Signature and Date
_______________:Date
INVOICE
Bill to:
SMG Mediquip
PO Box Box 736 Bethpage, NY 11714
Item / Device: __TENS Unit / supplies___
PATIENT NAME ADMINISTRATION Initial ________$ 50.00 Completed, reviewed and explained in full the agreement for the electro-therapy modalities and supplies, between patient and invoiced company. Explained the patient’s rights and obligations. Served as a focal point for distribution of the products furnished. Reviewed and/or made available to the patient the Notice of Privacy Practices.
INSTRUCTIONAL USAGE Initial ________$ 50.00 Instructed the above patient on the proper use the equipment. Explained why the item was prescribed and what the patient should expect from its effectiveness. Reviewed all warning and contraindications of the item.
MONITORING Initial ________$50.00 I have and continue to assess the above patient’s progress and compliance. Make all the initial settings and placements of the unit and electrodes on the above patient. Checked the equipment and supplies for malfunctions. I have determined the overall benefit for continued usage of the unit through the length of the requested prescription.
TOTAL:
$150.00
The equipment prescribed to the above patient was based solely on medical necessity. I am under no obligation to prescribe any equipment from the invoiced company. If necessary, I agree to furnish any supporting documentation (examination findings, office notes, progress notes, etc.) in order to verify the necessity, administration and monitoring of the prescribed item.
___________________________________________________ Signature and Date
INVOICE PHYSICIAN / P.T. NAME
TO: Southern States Analgesic 12311 Copper Way Ste 100 Charlotte, NC 28277 PATIENT NAME ADMINISTRATION Initial ________$ 75.00 Completed, reviewed and explained in full the agreement for the electro-therapy modalities and supplies, between patient and Southern States Analgesic, Inc. Explained the patient’s rights and obligations. Served as a focal point for distribution of the products furnished. Reviewed and/or made available to the patient the SSA Notice of Privacy Practices.
INSTRUCTIONAL USAGE Initial ________$ 75.00 Instructed the above patient on the proper use and functioning of the unit. Explained why the unit was prescribed and what the patient should expect from its effectiveness. Reviewed all warning and contraindications of the unit.
MONITORING Initial ________$100.00 I have and continue to assess the above patient’s progress and compliance. Make all the initial settings and placements of the unit and electrodes on the above patient. Checked the equipment and supplies for malfunctions. I have determined the overall benefit for continued usage of the unit through the length of the requested prescription. TOTAL:
$250.00
The equipment prescribed to the above patient was based solely on medical necessity. I am under no obligation to prescribe any equipment from Southern States Analgesic Inc. If necessary, I agree to furnish any supporting documentation (examination findings, office notes, progress notes, etc.) in order to verify the necessity, administration and monitoring of the prescribed unit.
___________________________________________________ Signature and Date
PATIENT AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION 1. I, __________________________, hereby authorize Southern States Analgesic Inc.. (The “Practice”) to use and/or disclose to Health Insurance Agencies, Attorney’s, Business Associates, and Southern States Analgesic Inc Employees, the following specific protected health information. Personal Health Information, The Care and Treatment Receiving or Received, and Relevant Personal Data. I understand that his authorization is valid for two years from the date of signature, unless otherwise specified. 2. I understand that the purpose or use of the disclosure I am granting is for the purpose of Treatment, Authorization, Payment and/or Health Care Operations. 3. I expressly acknowledge that this authorization is voluntary. 4. The following is/are other criteria or limitations that I make regarding this authorization;______________________________________________________. 5. I understand that the office will not receive financial or in-kind compensation in exchange for using or disclosing the health information described above. (Excluding payments for claims submission.) 6. I understand that this authorization may be revoked by the authorizer, in writing at any time in accordance with the attached authorization revocation procedure. I also understand that the revocation of this authorization will not have any effect on the disclosure occurring prior to the execution of any revocation. 7. I understand that the information used or disclosed pursuant to this authorization may be subject to being disclosed again by the recipient and that this information will no longer be protected by federal privacy regulations. 8. I understand that I may see and copy the information described in this form, if I ask for it, and that I will get a copy of this form after I sign it. 9. This form was completely filled in before I signed it. I certify that all of my questions were answered to my satisfaction and that I understand that this authorization for and all of its contents. 10. This authorization is valid as of the date I have signed below. You can obtain a copy of Southern States Analgesic Inc. HIPAA Privacy Policy and Notice upon request from the treating physician on behalf of southern states Analgesic, Inc. ____________________________ Name of Patient (Printed)
_________________________ Witness / Relationship
____________________________ Signature of Patient
_______________________ Date
2
HIPAA Authorization
Prescription Form-- Letter of Medical Necessity Physician notes, previous treatments
866-633-6261
866-633-6262 fax
Kimberly Schreiber
Patient Name:
Patient Date of Birth
Patient Address
Patient Phone (Auto or W/C) Claim # (Auto or W/C) Date of Accident
Patient Data & Lien
Insurance Co.
Insurance ID #
Insurance Phone
Group # Insured's Name
Patient Agreement
SMG Mediquip Inc (hereinafter referred to as *The Company) will be the supplier. I understand that this equipment is to be used for my diagnosed condition and is issued under a doctor’s prescription. I absolve The Company of responsibility as a result of any accident or injury caused directly or indirectly while using the equipment. I authorize The Company to provide supplies as needed. I authorize the release of medical records to The Company in order to determine benefits and to assist in correspondence with any third parties regarding collections of benefits on my behalf. I authorize payment of medical benefits directly to The Company. A copy of this authorization is as valid as the original. I understand that The Company is HIPAA compliant and will protect my privacy with regard to my medical and personal information. I acknowledge receipt of “Notice of Privacy Practices and CMS Medicare DMEPOS SUPPLIER STANDARDS”. By my signature below, I am acknowledging receipt of this equipment.
Patient Signature
Date
Serial #
Physician Notes / Previous Treatments / Letter of Medical Necessity
Equipment Prescribed : (
)
TENS / EMS unit Purchase
(
) E0855 Cervical Traction Device
(
)
Supplies for TENS/EMS
(
) Water Circul. heat/cold pump w/pad
(
)
L0631 Lumbar Brace
(
) Pad for water circulation heat unit
(
)
Other
(
) Conductive Brace / Wrap / Garment Lumbar
Knee
Ankle
Recommended Usage: Period :
Area to be treated
Prognosis
ICD ( Codes Applicable)
Excellent
Good
Fair
Guarded
Area to be treated Previous Treatments Pain Severity
Chronic Mild
Severe
Intractable
Moderate
Date First Diagnosed
Symptoms:
Date Last Seen
I certify that the above prescribed equipment, as provided by SMG Mediquip Inc is both reasonable and medically necessary as part of my treatment plan for this patient's condition as stated herein. This prescription is valid for one year from the date indicated unless otherwise noted. I authorize no substitute for the equipment prescribed. PO Box 550747 Physician's Signature
Date
Address
Atlanta
GA
30355
Dr. Alesia Reynolds
City
State
Zip Code
Printed Name
404-477-1797
404-477-1897
Phone
Fax
NPI
1
Patient Data / Script
Prescription Form-- Letter of Medical Necessity Physician notes, previous treatments
866-633-6261
866-633-6262 fax
1
Patient Data / Script
INVOICE
Bill to:
Advance Medical Inc
PO Box Box 340431 Tampa, FL 33694
Item / Device: _________________
PATIENT NAME ADMINISTRATION Initial ________$ 50.00 Completed, reviewed and explained in full the agreement for the electro-therapy modalities and supplies, between patient and invoiced company. Explained the patient’s rights and obligations. Served as a focal point for distribution of the products furnished. Reviewed and/or made available to the patient the Notice of Privacy Practices.
INSTRUCTIONAL USAGE Initial ________$ 50.00 Instructed the above patient on the proper use the equipment. Explained why the item was prescribed and what the patient should expect from its effectiveness. Reviewed all warning and contraindications of the item.
TOTAL:
$100.00
The equipment prescribed to the above patient was based solely on medical necessity. I am under no obligation to prescribe any equipment from the invoiced company. If necessary, I agree to furnish any supporting documentation (examination findings, office notes, progress notes, etc.) in order to verify the necessity, administration and monitoring of the prescribed item.
___________________________________________________ Signature and Date
_______________:Date
INVOICE
Bill to:
SMG Mediquip
PO Box Box 736 Bethpage, NY 11714
Item / Device: __TENS Unit / supplies___
PATIENT NAME ADMINISTRATION Initial ________$ 50.00 Completed, reviewed and explained in full the agreement for the electro-therapy modalities and supplies, between patient and invoiced company. Explained the patient’s rights and obligations. Served as a focal point for distribution of the products furnished. Reviewed and/or made available to the patient the Notice of Privacy Practices.
INSTRUCTIONAL USAGE Initial ________$ 50.00 Instructed the above patient on the proper use the equipment. Explained why the item was prescribed and what the patient should expect from its effectiveness. Reviewed all warning and contraindications of the item.
MONITORING Initial ________$50.00 I have and continue to assess the above patient’s progress and compliance. Make all the initial settings and placements of the unit and electrodes on the above patient. Checked the equipment and supplies for malfunctions. I have determined the overall benefit for continued usage of the unit through the length of the requested prescription.
TOTAL:
$150.00
The equipment prescribed to the above patient was based solely on medical necessity. I am under no obligation to prescribe any equipment from the invoiced company. If necessary, I agree to furnish any supporting documentation (examination findings, office notes, progress notes, etc.) in order to verify the necessity, administration and monitoring of the prescribed item.
___________________________________________________ Signature and Date
INVOICE PHYSICIAN / P.T. NAME
TO: Southern States Analgesic 12311 Copper Way Ste 100 Charlotte, NC 28277 PATIENT NAME ADMINISTRATION Initial ________$ 75.00 Completed, reviewed and explained in full the agreement for the electro-therapy modalities and supplies, between patient and Southern States Analgesic, Inc. Explained the patient’s rights and obligations. Served as a focal point for distribution of the products furnished. Reviewed and/or made available to the patient the SSA Notice of Privacy Practices.
INSTRUCTIONAL USAGE Initial ________$ 75.00 Instructed the above patient on the proper use and functioning of the unit. Explained why the unit was prescribed and what the patient should expect from its effectiveness. Reviewed all warning and contraindications of the unit.
MONITORING Initial ________$100.00 I have and continue to assess the above patient’s progress and compliance. Make all the initial settings and placements of the unit and electrodes on the above patient. Checked the equipment and supplies for malfunctions. I have determined the overall benefit for continued usage of the unit through the length of the requested prescription. TOTAL:
$250.00
The equipment prescribed to the above patient was based solely on medical necessity. I am under no obligation to prescribe any equipment from Southern States Analgesic Inc. If necessary, I agree to furnish any supporting documentation (examination findings, office notes, progress notes, etc.) in order to verify the necessity, administration and monitoring of the prescribed unit.
___________________________________________________ Signature and Date
PATIENT AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION 1. I, __________________________, hereby authorize Southern States Analgesic Inc.. (The “Practice”) to use and/or disclose to Health Insurance Agencies, Attorney’s, Business Associates, and Southern States Analgesic Inc Employees, the following specific protected health information. Personal Health Information, The Care and Treatment Receiving or Received, and Relevant Personal Data. I understand that his authorization is valid for two years from the date of signature, unless otherwise specified. 2. I understand that the purpose or use of the disclosure I am granting is for the purpose of Treatment, Authorization, Payment and/or Health Care Operations. 3. I expressly acknowledge that this authorization is voluntary. 4. The following is/are other criteria or limitations that I make regarding this authorization;______________________________________________________. 5. I understand that the office will not receive financial or in-kind compensation in exchange for using or disclosing the health information described above. (Excluding payments for claims submission.) 6. I understand that this authorization may be revoked by the authorizer, in writing at any time in accordance with the attached authorization revocation procedure. I also understand that the revocation of this authorization will not have any effect on the disclosure occurring prior to the execution of any revocation. 7. I understand that the information used or disclosed pursuant to this authorization may be subject to being disclosed again by the recipient and that this information will no longer be protected by federal privacy regulations. 8. I understand that I may see and copy the information described in this form, if I ask for it, and that I will get a copy of this form after I sign it. 9. This form was completely filled in before I signed it. I certify that all of my questions were answered to my satisfaction and that I understand that this authorization for and all of its contents. 10. This authorization is valid as of the date I have signed below. You can obtain a copy of Southern States Analgesic Inc. HIPAA Privacy Policy and Notice upon request from the treating physician on behalf of southern states Analgesic, Inc. ____________________________ Name of Patient (Printed)
_________________________ Witness / Relationship
____________________________ Signature of Patient
_______________________ Date
2
HIPAA Authorization
Prescription Form-- Letter of Medical Necessity Physician notes, previous treatments
866-633-6261
866-633-6262 fax
Kimberly Schreiber
Patient Name:
Patient Date of Birth
Patient Address
Patient Phone (Auto or W/C) Claim # (Auto or W/C) Date of Accident
Patient Data & Lien
Insurance Co.
Insurance ID #
Insurance Phone
Group # Insured's Name
Patient Agreement
SMG Mediquip Inc (hereinafter referred to as *The Company) will be the supplier. I understand that this equipment is to be used for my diagnosed condition and is issued under a doctor’s prescription. I absolve The Company of responsibility as a result of any accident or injury caused directly or indirectly while using the equipment. I authorize The Company to provide supplies as needed. I authorize the release of medical records to The Company in order to determine benefits and to assist in correspondence with any third parties regarding collections of benefits on my behalf. I authorize payment of medical benefits directly to The Company. A copy of this authorization is as valid as the original. I understand that The Company is HIPAA compliant and will protect my privacy with regard to my medical and personal information. I acknowledge receipt of “Notice of Privacy Practices and CMS Medicare DMEPOS SUPPLIER STANDARDS”. By my signature below, I am acknowledging receipt of this equipment.
Patient Signature
Date
Serial #
Physician Notes / Previous Treatments / Letter of Medical Necessity
Equipment Prescribed : (
)
TENS / EMS unit Purchase
(
) E0855 Cervical Traction Device
(
)
Supplies for TENS/EMS
(
) Water Circul. heat/cold pump w/pad
(
)
L0631 Lumbar Brace
(
) Pad for water circulation heat unit
(
)
Other
(
) Conductive Brace / Wrap / Garment Lumbar
Knee
Ankle
Recommended Usage: Period :
Area to be treated
Prognosis
ICD ( Codes Applicable)
Excellent
Good
Fair
Guarded
Area to be treated Previous Treatments Pain Severity
Chronic Mild
Severe
Intractable
Moderate
Date First Diagnosed
Symptoms:
Date Last Seen
I certify that the above prescribed equipment, as provided by SMG Mediquip Inc is both reasonable and medically necessary as part of my treatment plan for this patient's condition as stated herein. This prescription is valid for one year from the date indicated unless otherwise noted. I authorize no substitute for the equipment prescribed. PO Box 550747 Physician's Signature
Date
Address
Atlanta
GA
30355
Dr. Alesia Reynolds
City
State
Zip Code
Printed Name
404-477-1797
404-477-1897
Phone
Fax
NPI
1
Patient Data / Script
Prescription Form-- Letter of Medical Necessity Physician notes, previous treatments
866-633-6261
866-633-6262 fax
1
Patient Data / Script
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