AUTHORIZATION/CONSENT FOR CARE/SERVICE: I have been informed of the home care options available to me and of the selection of providers from which I may choose. I authorize Aeroflow under the direction of the prescribing physician, to provide home medical equipment, supplies and services as prescribed by my physician or authorized by my insurance provider.
ASSIGNMENT OF BENEFITS/AUTHORIZATION FOR PAYMENT: I hereby assign all benefits and payments to be made directly to Aeroflow, Inc. for any home medical equipment, supplies and services furnished to me in conjunction with my home care. I authorize Aeroflow to seek such benefits and payments on my behalf. It is understood that, as a courtesy, Aeroflow will bill payers and insurer(s) providing coverage, with a copy to Aeroflow. I understand that I am responsible for providing all necessary information and for making sure all certification and enrollment requirements are fulfilled. Any changes in the policy must be reported to Aeroflow within 10 days of the event.
RELEASE OF INFORMATION: I hereby request and authorize Aeroflow, the prescribing physician, hospital, and any other holder of information relevant to service, to release information upon request, to Aeroflow, any payer source, physician, or any other medical personnel or agency involved with service. I also authorize Aeroflow to review medical history and payer information for the purpose of providing home health care.
FINANCIAL RESPONSIBILITY: I understand and agree that I am responsible for the payment if any and all sums that may become due for the services provided. 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, Aeroflow does not receive payment from my payer source, I hereby agree to pay Aeroflow for the balance in full, within 30 days of receipt of invoice. All charges not paid within 30 days of billing date shall be assessed late charges. I am liable for all charges, including collection costs and all attorneys cost. I am responsible for all charges regardless of my payer unless my agreement with my health plan holds me harmless.
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: By signing and submitting this form, I consent to receive phone calls, e-mails, texts, and pre-recorded messages from Aeroflow Inc. or one of our relevant partners regarding our products and services, at the phone number(s) or email address provided; including my wireless number if provided I understand these calls may be generated using an automated technology.
CONSENT TO TEXT: 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.
REFER A MAMA GIVEAWAY: The Refer A Mama Giveaway is 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. Aeroflow Breastpumps will choose one random winner at the end of each promotion. The winner will be notified via email and will have five business days to respond. If no response is received, the winner forfeits the prize package. Aeroflow Breastpumps will, at their sole discretion, determine if another winner will be chosen. The company will have no liability for any losses or damages of any kind caused by prize possession. By participating in this giveaway, entrants agree to be bound by the contest rules. Subject to change without notice.
GRIEVANCE REPORTING: I acknowledge that I have been informed of the procedure to report a grievance should I become dissatisfied with any portion of my home care experience. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call 888-345-1780 and speak to the Customer Services Supervisor. If your complaint is not resolved to your satisfaction within 5 working days, you may initiate a formal grievance, in writing and forward it to the Board of Directors. You can expect a written response within 7 working days of receipt.
ABOUT FINANCIAL ARRANGEMENTS AND HEALTH INSURANCE: We are committed to providing you with the best possible care. If you have medical insurance, we are committed to helping you receive your maximum allowed benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policy. Payment for services is due at the time services are rendered unless payment arrangements have been approved in advance by our staff. We accept cash, checks, & most major credit cards. We will be happy to help you process your insurance claims for reimbursement of the services. Balances older than 90 days may be subject to additional collection fees and interest charges of 1.5 % per month. We must emphasize that, as healthcare providers, our relationship is with you, not your insur ance company. While the filing of the insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. 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. If you have any questions about the above information or any uncertainty regarding your insurance coverage, PLEASE don’t hesitate to ask us. We are here to help you.
I am the patient or the patient's authorized representative and agree to the terms and conditions contained in this form and any other documentation provided by Aeroflow Healthcare (collectively, this "Agreement"), including the following:
I have been informed by Aeroflow of the medical necessity for the services prescribed by my physician or authorized by my insurance provider. I understand that in the event services are deemed not reasonable and necessary, payment may be denied and that I will be fully responsible for payment.
Terms and Conditions
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 Aeroflow Inc. d/b/a Aeroflow Healthcare (“Aeroflow '') 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 Aeroflow, Inc. for any Aeroflow furnished home medical equipment, products and services. Aeroflow will seek such benefits and payments on the patient’s behalf. It is understood that, as a courtesy, Aeroflow will bill Medicare/Medicaid or other federally funded sources and other payers and insurer(s) providing coverage, with a copy to Aeroflow. 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 Aeroflow within 10 days of the change.
Release of Information
The patient or representative requests and authorizes Aeroflow, the prescribing physician, hospital, and any other holder of information relevant to service or equipment provided by Aeroflow, to release information upon request, to Aeroflow, any payer source, physician, or any other medical personnel or agency involved with service. The patient also authorizes Aeroflow to review medical history and payer information for the purpose of providing treatment, equipment or products.
Due to federal and state pharmacy regulations, equipment prescribed and sold for home health care cannot be re-dispensed and cannot be returned for credit. The patient or their representation must notify Aeroflow within 24 hours if the set-up of any equipment is improper or the equipment is defective. In the event of defective equipment, Aeroflow will exchange the equipment.
Rented home medical equipment must be returned to Aeroflow when the physician orders discontinuance or when the patient is deceased.
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 Aeroflow or any of its subsidiaries regarding Aeroflow products and services, at the phone number(s) or email address provided; including wireless number if provided. These calls may be generated using an 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 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 Aeroflow 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.
Replacement Equipment & Warranty Information
Aeroflow is only responsible for equipment repairs and replacement for rented equipment during the rental period. The patient or their representative will be notified of warranty coverage for any covered Aeroflow equipment sold or rented. Aeroflow will honor all warranties under applicable law and according to manufacturer's guidelines. The patient will need to refer to the manufacturer's warranty guidelines for what constitutes a voided warranty.
Information for Medicare Patients
The products and/or services provided to the patient by Aeroflow 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/
After Hours Voicemail Service
Aeroflow maintains accessibility through our after-hours voicemail service and can be reached by calling the main telephone number (888-345-1780). All voicemails will be received and returned on the next business day. This service is free to patients/clients. The recorded message advises patients that calls will be returned within the next business day and are advised that if a life-threatening medical emergency arises, the patient or caregiver should contact their local emergency services number immediately for assistance (usually 911).
Medicare Capped Rental
If the patient’s service or equipment is covered by Medicare, Medicare will pay a monthly rental fee for a period not to exceed 13 months, after which ownership of the equipment is transferred to the Medicare beneficiary/patient. After equipment ownership is transferred, it is the beneficiary/patient's responsibility to arrange for any required equipment service or repair through the manufacturer. Examples of this type of equipment include, but not limited to nebulizers, enteral pumps, and CPAP/BIPAP/ASV/RAD.
Scope of Services
Aeroflow has the following services available for patients: breast pumps, incontinence supplies, catheters, CPAP/BIPAP/ASV/RAD equipment & supplies, nebulizers, compression, bracing, enteral nutrients, continuous glucose monitoring and supplies, and ostomy.
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 Aeroflow 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, Aeroflow 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. Aeroflow accepts cash, checks, & most major credit cards.
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 attorney’s 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.
Please be advised there is a $25.00 fee for all returned checks.
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, Aeroflow 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 Aeroflow 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.
Communication with Minors
We are committed to protecting the privacy of children. Aeroflow'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 Aeroflow, submit personal information, or place orders.
Patient Complaint / Grievance Process
In the event the patient should become dissatisfied with any portion of their Aeroflow provided home care experience, a complaint may be lodged with Aeroflow without concern for reprisal, discrimination, or unreasonable interruption of service. The patient has the right to present questions or grievances to an Aeroflow staff member and to receive a response in a reasonable period of time. For concerns regarding quality of care or other services, please contact Aeroflow’s office by phone or mail. Grievances can also be reported to the NC Division of Services intake unit, Medicare, or Aeroflow’s Medicare accreditation agency, ACHC. All contact information and our process for handling complaints can be found below.
The following procedure details the steps that Aeroflow will take when a client’s/patient’s complaint/grievance is received:
After receiving the concern, the Aeroflow Customer Service Supervisor will take the following steps:
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 the 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: Aeroflow Urology will send patient surveys via email after 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.
Patient Satisfaction Surveys
Aeroflow conducts weekly patient satisfaction surveys. All inbound callers who have not been surveyed in the last 60 days will receive a survey request. Surveys are sent out every Monday to the patient’s telephone number. Data collected/analyzed from previous surveys every Monday after new surveys are sent. Survey results are sent out to all managers each Monday. By signing below, you acknowledge that you have been informed of this patient satisfaction survey procedure.
I am the patient or the patient's authorized representative and agree to the terms and conditions contained in this form and any other documentation provided by Aeroflow Healthcare (collectively, this "Agreement"), including the following:
- I have been informed by Aeroflow of the medical necessity for the services prescribed by my physician. I understand that in the event my insurer deems that services are not reasonable and necessary, my insurer may deny payment and I will be fully responsible for payment.
- I acknowledge that the Responsible Party (as defined in this document) is primarily responsible to pay the charges for the equipment and services listed in this agreement and may be charged for any loss or damage to any rental equipment.
- I have notified Aeroflow of any changes to the insurance or if the patient has joined a Medicare managed care program. I will immediately notify Aeroflow of any such changes in the future.
- I have received and fully inspected the equipment listed in this agreement and it is complete and in good working order without defects.
- I have been instructed on the proper care, use, service, safe operation, and maintenance of the equipment listed in this Agreement as appropriate.
- I have been instructed and understand the warranty coverage.
Patient / Guardian Signature ___________________ Date _______________
Print Name ________________
If the patient is unable to sign, what is the reason? _____________________________________________________
Representative's Address and phone # ______________________________________________
Refer a Friend, Unstoppable, and Social Media Giveaways
The Refer A Friend Giveaway, Unstoppable Giveaway, and any giveaway hosted on an Aeroflow Urology’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. Aeroflow Urology will choose the winner(s) at the end of each promotion. The winner(s) will be notified via email and will have five business days to respond. If no response is received, the winner forfeits the prize package. Aeroflow Urology will, at their sole discretion, determine if another winner will be chosen. The company will have no liability for any losses or damages of any kind caused by prize possession. By participating in each giveaway, entrants agree to be bound by the contest rules. Subject to change without notice.
Customer Orientation Checklist
- Patient Service Agreement
- Release of Information Agreement
- Assignment of Benefits
- Where to access Medicare DMEPOS Supplier Standards
- Advanced Directives
- Delivery Ticket/invoice denoting equipment delivered
- Client/Patient Bill of Rights & Responsibilities
- Home safety information
- Equipment, Supply, Cleaning and Maintenance procedures (included with equipment)
- Important company phone numbers
- Scope of services
- Warranty Information
- Complaint resolution protocol, along with important state and federal contact phone numbers
- Purchase options for capped rentals and information on purchasing inexpensive or routinely purchased DME
- Infection control
- Plan of care (if applicable)
- Emergency planning and patient emergency contact information
- Patient Satisfaction Survey (sent out separately)
- I understand that Aeroflow prohibits smoking by employees while providing services to an individual's home.
- HIPAA Notice of Privacy Practice
By signing below, I understand and agree that I have received the information above and agree to abide by all of the guidelines, including local, state and federal laws.
Patient/POA Signature: _______________ Date: ____________________
Print Name _________________________
Aeroflow Representative Signature: ________________Date: ______________________
**Required** Emergency Contact Name: __________________________________________
Emergency Contact Phone Number: ________________________________________________
If patient does not have an emergency contact, list the reason:
Effective Date: 07/01/2020
Medical Information & Plan of Care
Email Address: _______________________ Phone # :_______________________________
Cell #:_________________________ Emergency Contact Name and Number: ____________________________________________
Place a check mark beside the Yes or No based on Patient's response.
|Noticeable Fire Hazards|
|Patient or Others Who Smoke|
|Able to Manage Self Care|
|Able to Operate Equipment|
|Knowledge, Memory Impairment|
|Alarm / Troubleshooting|
|Comprehends Reason for Equipment|
|Infection Control / Cleaning Understanding|
|Extra Instructions Needed|
|Adequate Entrance and Exit to Home|
|Adequate Space to Maneuver Throughout Home|
|Able to Access Restroom and Kitchen|
Was the patient able to safely and adequately maneuver and operate the delivered equipment?
__________NO Are there any specific areas of concern? _____________YES
If yes, what?
Problem/Need: See diagnosis and prescription
GOAL: Patient/Caregiver will be knowledgeable in the safe operation, cleaning, and troubleshooting of delivered equipment.
Technician Signature:__________________________ Date _______________
Patient/Guardian Signature: _____________________________ Date ________________
What is an Advance Directive? An advance directive is a set of directions you give about the medical and mental health care you want if you ever lose the ability to make decisions for yourself. There are two ways for you to make a formal advance directive. These include: Living Wills and Healthcare Powers of Attorney. Forms & additional information may be obtained from the Secretary of State website.
Do I have to have an Advance Directive and what happens if I don't? Making an advance directive is your choice. If you become unable to make your own decisions, and you have no advance directive, your physician or mental health care provider will consult with someone close to you about your care. Discussing your wishes with your family and friends now will help ensure that you get the level of treatment you want when you can no longer tell your health providers what you want.
What is a Living Will? A Living Will is a legal document that tells others that you want to die a natural death if you: become incurably sick with an irreversible condition that will result in your death within a short period of time; are unconscious and your physician determines that it is highly unlikely you will regain consciousness; or have advanced dementia or a similar condition which results In a substantial cognitive loss and it is highly unlikely the condition can be reversed. You can direct your physician not to use certain life-prolonging treatments such as a breathing machine ("respirator" or "ventilator"), or to stop giving you food and water through a tube ("artificial nutrition or hydration" through feeding tubes and IVs). The document goes into effect only when your physician and one other physician determine that you meet one of the conditions specified in the Living Will. You can cancel anytime by communicating your intent to cancel it in any way.
What is a Healthcare Power of Attorney? A Healthcare Power of Attorney is a legal document in which you can name a person(s) as your health care agent(s) to make medical and mental health decisions for you if you become unable to decide for yourself. You can say which treatments you would want and not want. You should choose an adult you trust to be your health care agent. Discuss your wishes with that person(s) before you put them in writing. The document will go into effect when a physician states in writing that you are not able to make or to communicate your health care choices. You can cancel or change while you are able to make and communicate your decisions.
How do I make an Advance Directive? There are several rules to protect you and ensure your wishes are clear to the physician who may be asked to carry them out. An advanced directive must be: (1) written; (2) signed by you while you are still able to make and communicate health care decisions; (3) witnessed by two qualified adults; and (4) notarized. A qualified witness is a competent adult who sees you sign, is not a relative, and will not inherit anything from you upon your death. The witness cannot be your physician, a licensed employee of your physician or any paid employee of a healthcare facility where you live or that is treating you.
Who should I talk to about an Advance Directive? You should talk to those closest to you about an advance directive and your feelings about the health care you would like to receive. Your physician or health care provider can answer medical questions. A lawyer can answer questions about the law. Give copies to your family, your physician or mental health providers, your health care agent(s), and any family members or close friends who might be asked about your care should you become unable to make decisions. Please furnish Aeroflow with a copy of your advance directives.
It is the policy of Aeroflow to conform to the acceptable standards of infection control pertaining to equipment and home health services issued by the Centers for Disease Control (CDC) and the Occupational Safety and Health Administration (OSHA), in order to ensure the safety of clients/patients and employees, and also to ensure quality client/patient service
How infections occur and are spread: An infection occurs when germs enter the body, increase in number, and cause a reaction of the body.
Three things are necessary for an infection to occur:
- Source: Places where infectious agents (germs) live (e.g., sinks, surfaces, human skin)
- Susceptible Person with a way for germs to enter the body
- Transmission: a way germs are moved to the susceptible person
There are a few general ways that germs travel in healthcare settings:
- Through contact (i.e., touching)
- Sprays and splashes (when an infected person coughs or sneezes)
- Inhalation (when germs are aerosolized in tiny particle)
- Sharp injuries (i.e., when someone is accidentally stuck with a used needle or sharp instrument).
How to prevent infection:
- Wash your hands often
- Get vaccinated
- Get vaccinated and use antibiotics sensibly
- Stay at home if you have signs and symptoms of an infection.
- Cover your mouth and nose
- Disinfect the 'hot zones' in your residence - the kitchen and bathroom
- Don't share personal items
- Make sure health care providers clean their hands or wear gloves
- Clean equipment and supplies regularly
- Replace equipment on a regular schedule. Contact Aeroflow (888-345-1780) when your supplies are to be thrown out.
Symptoms of Hepatitis infection: Extreme fatigue, mild fever, headache, loss of appetite, nausea, and vomiting. Symptoms of Tuberculosis (TB) infection: fatigue, anorexia, productive cough, coughing up blood, weight loss, loss of appetite, lethargy, weakness, night sweats, chills, flu-like symptoms and fever. Some people with TB may show no symptoms. NOTIFY YOUR HEALTHCARE PROVIDER IF YOU FEEL YOU HAVE BECOME INFECTED.
How to Make Your Home Safe for Medical Care
At Aeroflow, we want to make sure that your home medical treatment is done conveniently and safely. Many of our clients/patients are limited in strength, or unsteady on their feet. Some are wheelchair or bed-bound. These pages are written to give our clients/patients some easy and helpful tips on how to make the home safe for home care. Discuss these plans with your family members.
Fire Safety and Prevention
- Smoke detectors should be installed in your home: make sure you check the batteries at least once a year. If appropriate, you may consider carbon monoxide detectors as well. Ask your local fire department if you should have one in your home.
- Have a fire extinguisher in your home, and have it tested regularly to make sure it is still charged in working order. And, have a plan for escape in the event of a fire.
- If you are using electrical medical equipment, make sure to review the instruction sheets for that equipment. Read the section on 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 that 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.
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, local 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 weeks' 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 (888-345-1780). 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).
HIPPA Notice of Privacy Practices
This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
- If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
Our Uses and Disclosures
We typically use or share your health information in the following ways:
We can use your health information and share it with other professionals who are treating you.
Run our organization
We can use and share your health information to run our business, improve your care, and contact you when necessary.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We must meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.
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 Aeroflow 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 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 Aeroflow’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 Aeroflow’s on-call service.
- Be informed of Aeroflow’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 Aeroflow’s policies and procedures regarding the disclosure of clinical records, clinical guidelines, and management of care
- Be advised of Aeroflow’s procedures for discharge.
- Report fraud, waste, or abuse
- Be notified within 10 days if Aeroflow’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:
- Client agrees that rental equipment will be used with reasonable care, not altered or modified, and returned in good condition (normal wear and tear excepted).
- Client agrees to promptly report to Aeroflow any malfunctions or defects in rental equipment so that repair/ replacement can be arranged.
- Client agrees to provide Aeroflow access to all rental equipment for repair/replacement, maintenance, and/or pick-up of the equipment.
- Client agrees to use the equipment for the purposes so indicated and in compliance with the physician’s prescription.
- Client agrees to keep the equipment in their possession and at the address, to which it was delivered unless otherwise authorized by Aeroflow
- Client agrees to notify Aeroflow of any hospitalization, change in customer insurance, address, telephone number, physician, or when the medical need for the rental equipment no longer exists.
- Client agrees to request payment of authorized Medicare, Medicaid, or other private insurance benefits are paid directly to Aeroflow for any services furnished by Aeroflow.
- Client agrees to accept all financial responsibility for home medical equipment furnished by Aeroflow
- Client agrees to pay for the replacement cost of any equipment damaged, destroyed, or lost due to misuse, abuse or neglect.
- Client agrees not to modify the rental equipment without the prior consent of Aeroflow
- Client agrees that any authorized modification shall belong to the titleholder of the equipment unless equipment is purchased and paid for in full.
- Client agrees that title to the rental equipment and all parts shall remain with Aeroflow at all times unless equipment is purchased and paid for in full.
- Client agrees that Aeroflow shall not insure or be responsible to the client for any personal injury or property damage related to any equipment; including that caused by use or improper functioning of the equipment; the act or omission of any other third party, or by any criminal act or activity, war, riot, insurrection, fire or act of God
- Client understands that Aeroflow retains the right to refuse delivery of service to any client at any time.
- Client agrees that any legal fees resulting from a disagreement between the parties shall be borne by the unsuccessful party in any legal action taken.
- Patients/Clients have the responsibility to give providers the information they need, in order to provide the best possible care and to ask questions about their care.
- Clients have the responsibility to treat those giving them care with dignity and respect and not to take actions that could harm others.
- Patients/Clients have the responsibility to understand and help develop and follow the agreed-upon treatment plans for their care, including the agreed-upon medication plan and to let the provider know when the treatment plan no longer works for them.
- Patients/Clients have the responsibility to keep their appointments. Patients should call their providers as soon as possible if they need to cancel visits.
- Patients/Clients have the responsibility to let their provider know about any changes to their contact information (name, address, phone, etc.) and insurance coverage.
- Patients/Clients have the responsibility to tell their provider about medication changes, including medications given to them by others.
- Patients/Clients have the responsibility to let their provider know about problems with paying fees.