NEW ENGLAND HOME MEDICAL EQUIPMENT

NEW ENGLAND HOME MEDICAL EQUIPMENT

21 Alpha Road, Chelmsford, MA 01824

978-221-2323

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Client Name (Printed)

Date of Birth

ACKNOWLEDGEMENT I acknowledge that I have received the New Client Packet which includes: Medicare Supplier Standards, Notice of Privacy Information and HIPAA, Client Bill of Rights, Warranty Coverage, Complaint Process.

To report concerns about patient safety and quality of care, please call New England Home Medical Equipment at 978-221-2323 and speak to the general manager. You may also contact the Accreditation Commission for Health Care at 855-937-2242 or send a letter to ACHC at 139 Weston Oaks Court, Cary, NC 27513.

ASSIGNMENT OF BENEFITS AND RELEASE OF AUTHORIZATION I request payment under my medical insurance to be made directly to the above named company in the event my medical insurance does not make payment I agree to be personally liable for all charges. I authorize any provider of my medical information to release any information necessary to determine services, benefits and payment on my behalf. I permit a copy of this authorization to be used in place of the original. I permit the review of my record by accrediting and licensing agents and/or for the purpose of quality control.

CUSTOMER AGREEMENT I have read and agree to each and all of the terms and conditions. I consent to receive services from the above named company.

HIPAA NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT OF RECEIPT BY PATIENT By signing below, I acknowledge that I have received a copy of New England Home Medical Equipment's HIPAA Notice of Privacy Practices.

RETURN POLICY Returns will be accepted within TEN business days with receipt. The item must be unopened and in resalable condition. Any credits will be in the same form as original payment.

__________________________________________________________ Client or Caregiver Signature

____________________ Date

__________________________________________________________ Relationship to Client (if applicable)

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