Terms of Agreement and Medical Consent:
I authorize provision of products or services to me by CSS. I also understand that I am under the control of my attending physician and that CSS is not liable for any act or omission when following the instructions of said physician.
I authorize direct payment to CSS of all Medicare, Medicaid, Medigap, and other insurance benefits otherwise payable to me for the following equipment, supplies, and/or services provided to me by CSS. If CSS does not accept assignment, insurance benefits shall be payable to the patient. I authorize my insurance company (ies) to furnish CSS and its agent’s any and all information pertaining to my insurance benefits and status of claims submitted by CSS for services rendered. I authorize any holder of medical information about me to release to CSS, CMS, Medicare, Medicaid and other insurers and their agents such information, as needed to determine benefits payable for items and services provided to me.
I authorize CSS to communicate with me with respect to the products and services rendered to me by CSS. These communications may include, but are not limited to, communications to establish my account with CSS, administrative notices, surveys, provider communications, and others categories. I recognize that some of these communications may be made through third party service providers that have agreed to the same privacy protections as CSS in regard to my health information. When I provide my contact information and/or alternatives to CSS, I consent to receiving information by such method(s), recognizing that some forms of communication may not be secure.
Acknowledgement of Financial Responsibility:
While there may be insurance coverage for products/services provided to me by CSS, not all products/services may be covered and coverage may be less than 100% of the billed charge. I understand that I am responsible for providing all necessary insurance information and for making sure all certification and enrollment requirements are met. I agree to pay all amounts not covered by my insurance, for which I am responsible. I agree to make payment to CSS within 30 days of receipt of a statement or invoice and consent that CSS can charge the credit card I provided them for any future past due payments, in accordance with the payment schedule in the applicable statement or invoice. A finance charge at the lesser of 1.5% per month or maximum amount allowed by law will be added to all past due balances. I also agree to pay any fees incurred by CSS to collect on my past due account.
Change in Patient’s Insurance or Condition:
I agree that any change in patient’s insurance will be promptly reported to CSS and failure to do so may result in patient responsibility for payment. If patient changes to an insurer not contracted with CSS, patient will be responsible for payment. I agree that I will promptly notify CSS if patient’s medical condition changes to render provided equipment no longer needed. I agree that I will promptly notify CSS if patient is admitted to a hospital or skilled nursing facility, and will provide CSS with correct date(s) of admission and discharge.
Confirmation of Receipt of Supplier Standards & Privacy Notice:
I have received, read, and understand my copy of the HIPAA Privacy Notice. The products and/or services provided to you by CSS 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://ecfr.gov/. Upon request we will furnish you a written copy.
I have been instructed and understand every product sold or rented by CSS carries a 1-year manufacturer’s warranty (unless otherwise noted). CSS will notify all Medicare beneficiaries of the warranty coverage, and will honor all warranties under applicable law. CSS 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.
Unused, unopened merchandise may be returned within 30 days of receipt for a full refund, excluding: garments, Medications, Sterile Products, rental merchandise, Enteral products & sanitary equipment that may come in contact with human discharge. Rental items will not be prorated. Special orders may not be returned. For a full copy of the policy, please review here.
I have received written/oral instruction for the safe operation, maintenance of my equipment, storage of supplies/medications and disposal of sharps, as appropriate. Infection control measures reviewed and understood. I understand that additional copies of instruction manuals and videos can be obtained in the resource center or furnished upon request.
Inexpensively or Routinely Purchased (IRP) Items & Capped Rental Notification:
I have been advised that CSS does not offer products as rental items if such product is defined by Medicare as IRP. If I choose to rent equipment, I may use another provider. I understand that equipment covered as a Medicare Capped Rental is patient owned at 13 months and is thereafter patient’s responsibility. Title is considered automatically transferred, unless notified otherwise.