CUSTOMER BILL OF RIGHTS
We believe that all customer receiving services from The Exquisite Fit, LLC should be informed of their rights. Therefore, you are entitled to:
- Be treated with dignity, courtesy, friendliness, and to have your personal property respected.
- Receive reasonable coordination and continuity of services form the referring agency to home medical equipment services.
- Receive a timely response from when home care equipment or additional information is needed or requested.
- Be fully informed of The Exquisite Fit, LLC policies, procedures and charges for services and equipment, including eligibility for third party reimbursement.
- Receive an explanation of all forms you are requested to sign.
- Receive home care equipment and services regardless of race, religion, political belief, sex, social status, age or handicap.
- Receive proper identification form personnel providing services.
- Participate in decisions concerning home care equipment needs, including the right to refuse service within the confines of the law.
- Participate in decisions surrounding the formulation of advance directives (i.e., living wills) and/or the consideration of ethical issues that may arise.
- Have all of your records (except as otherwise provided for by law or third party payer contracts) and all communications, written or oral, treated confidentially.
- Access to all health records pertaining to you and to challenge and have your records corrected for accuracy.
- Express dissatisfaction and suggest changes in any service without fear of coercion, discrimination, reprisal or unreasonable interruption in service.
- Receive information on The Exquisite Fit, LLC’s mechanism for receiving, reviewing and resolving complains or concerns.
- Be assured that your rights are honored by all The Exquisite Fit, LLC Staff.
- Be informed of your responsibilities regarding home care equipment and services.
CONSUMER COMPLAINT & ABUSE HOTLINES
* In the event of a complaint which is not resolved, the client or immediate family or caregiver has a right to report complaints, abusive, neglectful, or exploitive practices.
* To report a complaint regarding the services you receive: Please call BOC 877-776-2200
* PA State Consumer Complaint Line: 1-800-822-2113
* To report abuse, neglect, or exploitation of a disabled adult or elderly person: Please call 1-800-962-2873
* If you have any concerns or complaints with The Exquisite Fit, please contact Michael D. Stutzenburg, Compliant Officer, The Exquisite Fit, 724-591-5326 Ext. 102
* If your concerns meet the definition of an emergency situation: First call 911 then call the Abuse Hotline.
* To report Medicaid Fraud call: 1-866-966-7226
* To report Medicare Fraud call: 1-800-MEDICARE (1-800-633-4227)
- Customer agrees that rental equipment will be used with reasonable care, not altered or modified, and returned in good condition (normal wear expected). Rental equipment shall at all times remain the property of The Exquisite Fit, LLC.
- Customer agrees to promptly report to The Exquisite Fit, LLC any malfunctions or defects in rental equipment so that repair/replacement can be arranged.
- Customer agrees to provide The Exquisite Fit, LLC access to all rental equipment for repair/replacement, maintenance and/or pick-up of the equipment.
- Customer agrees to use the equipment for the purpose so indicated and in compliance with the physician’s prescription. Customer agrees to keep the equipment in their possession at the address to which it was delivered unless otherwise authorized by The Exquisite Fit, LLC.
- Customer agrees to notify The Exquisite Fit, LLC of any hospitalizations or change in health insurance, address, telephone number, physician or when the medical need for rental equipment no longer exists.
- Customer agrees to accept all financial responsibility for home medical equipment furnished by The Exquisite Fit, LLC.
ASSIGNMENT/SIGNATURE ON FILE AGREEMENT
I request that payment of authorized medical benefits be made to The Exquisite Fit, LLC for any covered service furnished to me. In cases where The Exquisite Fit, LLC agrees to accept assignment, The Exquisite Fit, LLC will accept the charge determination as the full charge for the covered services. I am always responsible for the deductible, co-insurance and unassigned uncovered services. I agree to pay The Exquisite Fit, LLC any payment made directly to me by insurance for services provided by The Exquisite Fit, LLC on an assigned basis. I understand that The Exquisite Fit, LLC does not accept returned merchandise if worn, used for sanitary or hygienic purposes, or if it is disposable. All rental equipment shall remain the property of The Exquisite Fit, LLC. It is my responsibility to inform The Exquisite Fit, LLC if I relocate, no longer need the equipment, or am admitted to a hospital or nursing center. I shall also inform The Exquisite Fit, LLC if the equipment is not working properly. I agree that in the even my insurance or other third party payor refuses to pay the rental or purchase price of the equipment or service that I will be responsible for those payments or shall return the equipment involved.
I authorize the release of any medical or other insurance information to process this claim. I also request payment of government benefits either to me or to The Exquisite Fit, LLC.