Dr.
DURABLE MEDICAL EQUIPMENT AND SUPPLIES
Many of the supply type items (compression stockings, support hose, and support socks) that are dispensed in this office by the doctor are not covered by various insurance companies. We offer a variety of various styles and brands for the convenience of our patients. We are not a Durbale Medical Equipment Supplier, nor do we have a DME number to submit claims to your insurance carrier. We will as a courtesy to you, provide a receipt containing the necessary information for you, if you choose to submit your receipt to your insurance carrier. You may also opt to obtain a prescription for these items and purchase them at your own DME supplier as an alternative.
COPIES OF MEDICAL RECORDS
Please note, our office charges a fee of $25 for copies of medical records. A release form signed by the patient requesting the specific documentation and the format in which they wish to receive it must be on file prior to release. **PLEASE NOTE IT MAY TAKE UP TO 30 DAYS TO PROCESS MEDICAL RECORD REQUESTS**
LEAVE OF ABSENCE/FMLA REQUESTS
We will provide our standard “back to work” slip on our letterhead at no charge to the patient. However company forms, FMLA, etc. that must be completed by the office/physician will result a charge of $25 per occurrence.
Please sign below to acknowledge and accept the policy for DME, Medical Records, and Leave of Absence FMLA requests.
Patient/responsible party’s signature Date
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