STRENGTH/ MOBILIBTY:

DIFFICULT WALKING CONDITIONS FOR ME INCLUDE:

WORK DETAILS:

MY DAILY ACTIVIES INCLUDE:

ShoppingPreparing mealsCleaning my homePerforming yardworkWalking the dog

LIVING SITUATION:

I live alone

I care for children at homeI must use stairs at homeThere are difficult walking conditions around my home

MY HOBBIES/OTHER ACTIVITIES INCLUDE:

Long walksHikingRunningGardening

By signing below, I certify that Ever-Care has made available to me a Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Ever-Care healthcare operations. The Notice of Privacy Practices also describes my rights and Ever-Care’s duties with respect to my protected health information. Ever-Care reserves the
right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, or asking for one at the time of my next appointment.

I, the undersigned, consent to be contacted by Ever-Care by phone call, e-mail, US Postal Service or other means to followup on my care.

By signing below, I understand that Ever-Care may use my likeness in a photograph or video as part of its marketing efforts including but not limited to publication in external communication and social media posts. I waive the right to
inspect or approve the finished product wherein my likeness occurs. Additionally, I waive any right to royalties or other compensation related to the use of those images.

I understand that by signing this agreement, I indicate my wish to purchase orthotic and/or prosthetic products or services, or both, from Ever-Care. I understand that I am under the supervision and care of my attending physician. Iu nderstand that my physician has prescribed the orthosis/prosthesis noted as part of my treatment. I also understand
that due to the nature of the products supplied by Ever-Care that they cannot be returned.

I, the undersigned, hereby authorize Ever-Care to request on my/our behalf and to collect directly all public and private insurance benefits due for products and/or services supplied to me by Ever-Care. In the event payments for insurance
benefits are made directly to any of the undersigned, the payee will endorse to Ever-Care all checks for such payments

By signing below, I authorize all medical personnel to provide information to Ever-Care concerning my medical history, as it may relate to my treatment. This includes collecting medical information from any physician, surgeon, medical facility
and/or physical therapist seen by me. Ever-Care will comply with all HIPAA rules and regulations.

By signing below, I agree to inform Ever-Care of any changes in my insurance coverage. If my insurance coverage changes or is terminated, I understand that I am responsible for all charges of services and devices delivered to me or in
fabrication.

I hereby authorize the release of any necessary information (including,but not limited to full medical records) to Ever-Care Orthotics Prosthetics, and the above named insurance company as Ever-Care deems necessary to obtain coverage and benefits, request authorization or other coverage approval or to dispute the disposition or non-inclusion of any claim for reimbursement. Whenever possible, an electronic copy should be faxed or emailed in lieu of postal mailing of any records.

I understand this consent is voluntary and that I may revoke this authorization at any time (except to the extent that action based on this consent has already been taken) by written, dated and signe communication.This consent will remain in effect no more than 1 year, or (365) days from the date a signed this consent. I also understand that my medical records may include mental health information,drug/alcohol information and/or HIV information. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer by protected by the federal HIPAA Privacy Rule. I understand I may refuse to sign this authorization. If I refuse, the identiied records will not be disclosed.

*If signed by anyone other than patient, state relationship and reason for patient’s inability to sign.

A photocopy or facsimile of this authorization will be considered valid unless otherwise speciied. 2017.

Ever-Care reserves the right to charge a $35 fee for missed appointments without 24 hour notice.In the event you miss your appointment or cancel on the same day, the fee will be added to your account and collected at the time of the next visit or over the phone.

All patients must complete a patient information form before seeing the practitioner. To provide proof of insurance,a driver’s license or other I.D. and insurance cards are required.Practitioners cannot start on a device until insurance benefits are verified.

Prescriptions are required for all orthotic and prosthetic services and/or supplies.It is the Patient’s Responsibility to obtain a prescription from your physician prior to being seen.If you are unable to furnish a prescriptionat the time of your appointment you will be given the option of resche duling your appointment.

Prescriptions are required for all orthotic and prosthetic services and/or supplies.It is the Patient’s Responsibility to obtain a prescription from your physician prior to being seen.If you are unable to furnish a prescriptionat the time of your appointment you will be given the option of resche duling your appointment.

Ever-Care is a participating provider with most insurance plans. If Ever-Care is a non- participating provider with your insurance plan, payment in full is expected at the time of delivery. Ever-Care will submit a claim on your behalf and you will be reimbursed directly from your plan based on your benefit amount.

Ever-Care collects all patient financial responsibility at the time of delivery. If Ever-Care is a participating provider with your insurance plan, any fee collected will be based on your plan’s benefit amount. If Ever-Care is a non- participating provider, you will be expected to pay the “estimated” secondary amount at the time of delivery.Ever-Care will submit a claim on your behalf and you will be reimbursed directly from your plan based on your benefit amount.

Knowing your insurance benefit is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage and any out of network benefits.

If you do not have any insurance coverage, it is Ever-Care’s policy that you pay for your device in full at the time of delivery. Ever-Care prices are representative of the usual and customary charge for our area. We accept Visa, MasterCard, American Express, and Discover, as well as checks, money orders and cash.

The charge for labor for all adjustments and repairs to devices after the 45 day warranty period is $55.00 (per 15 minutes) . This charge will be submitted to your insurance for reimbursement. If Ever-Care is a non- participating provider with your insurance; payment is expected at the time of service.

This financial policy is to clarify any questions you may have about your financial obligation to Ever-Care. If the account becomes delinquent (90+ days past due), Ever-Care may pursue collections procedures. You may be held responsible for all collections costs, including and not limited to our court filing fees, services of process costs, interest and attorney fees.

NO REFUNDS will be given for the following items: CUSTOM MADE ITEMS, PROSTHETIC SUPPLIES (LINERS, SLEEVES, SOCKS), NON- STOCK, and SPECIAL ORDER ITEMS. All other items will be reviewed on a case by case basis.

We are committed to ensuring you are completely satisfied with the services and care you receive at Ever-Care. However, if for any reason you wish to file a complaint, any staff member can assist you in this confidential matter.
You will be asked to complete a “Patient Complaint Form” to assist us in understanding your complaint or concern fully. Once the form is received, a company representative will investigate the complaint thoroughly and take the necessary actions to satisfy your complaint. To reach our complaint department, Call Isaac Muhammad at
(612) 354-4550 or email him at Isaacm@evercareop.com.

We are committed to preserving the privacy of your personal health information.In fact, we are required by law to protect the privacy of your medical information and to provide you with Notice describing
.

We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.

We may be required or permitted by certain laws to use and disclose your medical information for other purposes without your consent or authorization. As our patient, you have important rights relating to inspecting and copying your medical information that we maintain, amending or correcting that information, obtaining and accounting of our disclosures of your medical information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated.

We have available a detailed Notice of Privacy Practices which fully explains your rights and our obligations under the law. We may revise our Notice from time to time. The effective date at the top right hand side of this page indicates the date of the most current Notice in effect.

You have the right to receive a copy of our most current Notice in effect. If you have not yet reserved a copy of our current Notice, please ask at the front desk and we will provide you with a copy

Please contact our Compliance, Isaac Muhammad at 612-354-4550 or by email at Isaacm@evercareop.com if you have any questions, concerns or complaints about this notice or your medical information.

1. Receive appropriate services, as prescribed, in a professional manner without discrimination relative to age, sex, race, religion, ethnic origin, sexual orientation, physical or mental handicap, or source of payment

2. Receive considerate and respectful care by each individual representing Ever-Care Orthotics & Prosthetics.

3. Be fully informed as to our company policies and procedures regarding billing and collection of accounts

4. Participate in decisions regarding his/her own treatment, including establishment of goals and expected outcomes

5. Expect reasonable responses to his/her requests and concerns.

6. Be assured of confidential treatment of his/her personal and medical records, and the right to review receive copies of his/her records.

7. Prompt service in the event that an orthosis or prosthesis needs immediate repair or replacement. Such situations receive the highest priority and every effort is made to resolve the situation in the shortest period of time possible. Patients may call our office at any time with such needs. We have after-hours urgent call line.

8. Be fully informed of Medicare supplier standards that apply to our business.

Ever-Care Orthotics & Prosthetics. pledges to provide its patients with product and devices of the highest quality, free of defects and according to the patient’s prescription.

Ever-Care Orthotics & Prosthetics will make free of charge adjustments and repairs to orthotic and prosthetic devices during the 45 day warranty period so long the need for adjustment or repair is not due to the patient's physical changes, abuse, or undue rough wear. After the warranty period, charges for repairs and adjustments are $55.00 (per 30 minutes). Custom fabricated devices cannot be returned.

“Off the shelf” items cannot be returned for hygienic reasons. In the unlikely event of an off the shelf item having a defect, only the manufacturer’s warranty applies. We will contact the manufacturer on your behalf during the initial warranty period after delivery of your off the shelf product.

It is in your best interest to communicate with your practitioner on a timely basis and to allow us to resolve any problems you are experiencing as efficiently and quickly as possible. Failure to contact the treating practitioner or infrequent or non-use of a device during the warranty period does not extend the warranty nor does it absolve the patient from the responsibility for payment.

It is our goal to provide you with the best care possible, and we will make every attempt to meet your need. Please contact us if there is a question or concern. We stand by our work.

Note: This is an abbreviated version of the supplier standards every medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).

1. A supplier must be in compliance with all applicable federal and state licensure and regulatory requirements.

2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.

3. An authorized individual (one whose signature is binding) must sign the enrollment application for billing privileges.

4. A supplier must fill orders from its own inventory or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs or from any other federal procurement or non-procurement programs.

7. A supplier must maintain a physical facility on an appropriate site and must maintain a visible sign with posted hours of operation. The location must be accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.

8. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier's compliance with these standards.

9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited.

10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier's place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.

11. A supplier is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition see 42 CFR 424.57 (c) (11).

12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items and maintain proof of delivery and beneficiary instruction.

13. A supplier must answer questions and respond to complaints of beneficiaries and maintain documentation of such contacts.

14. A supplier must maintain and replace at no charge or repair directly or through a service contract with another company Medicare-covered items it has rented to beneficiaries.

15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.

16. A supplier must disclose these standards to each beneficiary it supplies a Medicare-covered item.

17. A supplier must disclose any person having ownership, financial or control interest in the supplier.

18. A supplier must not convey or reassign a supplier number (i.e., the supplier may not sell or allow another entity to use its Medicare billing number).

19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.

20. Complaint records must include the name, address, telephone number and health insurance claim number of the beneficiary; a summary of the complaint; and any actions taken to resolve it.

21. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.

22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals).

23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened.

24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.

25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.

26. A supplier must meet the surety bond requirements specified in 42 C.F.R. 424.57(c).

27. A supplier must obtain oxygen from a state-licensed oxygen provider.

28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f)

29. A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers.

30. A supplier must remain open to the public for a minimum of 30 hours per week except physicians (as defined in section 1848 (j)
(3) of the Act) or physical and occupational therapists or a DMEPOS supplier working with custom made orthotics and prosthetics

•Notice of Privacy Practices: You have the right to read Ever-Care Orthotics & Prosthetics.’s Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, and the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. We encourage you to read it carefully and completely before signing this Consent.

•Purpose of Consent: By signing this form, you consent for Ever-Care Orthotics & Prosthetics, LLC. to use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

"The products and/or services provided to you by Ever-Care Orthotics & Prosthetics, LLC. 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 athttp://ecfr.gpoaccess.gov. Upon request, we will furnish you a written copy of the Medicare Supplier standards." There is a current copy for viewing on our front wall.

I acknowledge that I did receive and either have read or will read the “Patient Bill of Rights”, “Warranty”, “Billing and Collection Policy” and “What goes into the cost of my orthosis/prosthesis?” as provided on the blue sheet given to me today.

I authorize Ever-Care Orthotics & Prosthetics, LLC. to act on behalf in helping me obtain payment from my insurance companies. I authorize payment directly to Ever-Care Orthotics & Prosthetics. I authorize the use of this form on all my insurance submissions. I permit a copy of this authorization to be used in place of the original.

I understand that I am personally, financially responsible for the charges, (including any amounts towards deductible(s) or for non–covered products by Medicare or my insurance company) for products and services provided to me, my spouse and my minor children. This includes services for which Medicare, or my insurance company has paid me directly. I understand this authorization will
remain in effect until I revoke it in writing.

I request that payment of authorized Medicare benefits be made on my behalf to Ever-Care Orthotics & Prosthetics. I understand that my signature requests that payments be made to Ever- Care Orthotics & Prosthetics and understand the use and release of my medical records as described above.
By accepting Medicare Assignment, Ever-Care Orthotics & Prosthetics agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is responsible only for the deductible, co-insurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.

I authorize staff of Ever-Care Orthotics & Prosthetics, LLC. to contact me by Phone, SMS and E- mail regarding various aspects of my medical care, which may include, but shall not be limited to appointments and product reminders. I understand that E-mail and standard SMS messaging are not confidential methods of communication, may be insecure and there may be a risk that a third party may read my message.

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