A Fitting Experience Mastectomy Shoppe, Inc. 2950 North State Road 7 #103 Margate, Florida 33063 (954) 978-8287 (800) 419-5475 WWW.AFITTINGEXPERIENCE.COM Store Policy & Consent Form Agreement CONSENT/AUTHORIZATION FOR SERVICE: I authorize A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. under the direction of a prescribing Physician, to provide after breast surgery supplies and services. ASSIGNMENT OF BENEFITS/AUTHORIZATION FOR PAYMENT: I hereby assign all benefits and payments to be made directly to A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. for any after breast surgery products, supplies and services furnished to me. I authorize A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. to seek such benefits and payments on my behalf. It is understood that as a courtesy, our staff will verify benefits and will bill Medicare, your HMO, PPO, and other payors and insurer(s) providing coverage. A FITTING EXPERIENCE will not guarantee your insurance benefits or “wipe-off” deductible balances or copayments. I understand that I am responsible for providing all necessary information and for making sure all certification and enrollment requirements are fulfilled. Any changes in the policy must be reported to A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. within 30 days of the event. I have been informed by A FITTING EXPERIENCE of the medical necessity for the services prescribed by my Physician. : If applicable, I have been notified prior to my fitting of the ADVANCED BENEFICIARY NOTICE OF NON-COVERAGE (ABN). Payment for products on MEDICARE BENEFICIARIES ONLY MEDICARE NON-ASSIGNED CLAIMS is expected at the time of service. Beneficiary will be reimbursed directly from Medicare/Supplement. PLEASE INTIAL: * GRIEVANCE REPORTING: I acknowledge that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruptionof service. To place a grievance, please call: (954) 978-8287 and speak with facility manager on duty. If your complaint is not resolved to your satisfaction within five (5) business days, you may initiate a formal grievance in writing and forward it to: A Fitting Experience 2950 N. State Rd. 7 Suite #103 Margate, Florida 33063 ATTN.: GOVERNING BODY Thank You for choosing A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. as your specialty provider. We are honored by your choice and are committed to providing you with the highest quality products and services. We look forward to establishing a lasting relationship. As part of this relationship, we have outlined our expectation for your financial responsibility. Please read this document thoroughly and if you have any questions, please feel free to contact our office staff at (954) 978-8287. YOUR RESPONSIBILITY begins when you call to make an appointment. Please know your insurance. Be aware of what they pay for and do not pay for, as well as any co-pay and deductibles. COPAYMENTS AND DEDUCTIBLES: Co-pays are collected at the time of check-in. Insurance deductibles and fees for services not covered by your insurance policy, if known, are due at the time the service and merchandise is rendered. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your portion due. We accept Cash, Check, and most major credit cards. UNPAID BALANCES: Unpaid balances are ultimately the responsibility of the insured. APPOINTMENT CANCELLATION POLICY: In most cases, our Staff works diligently works to obtain Referrals, Authorizations, Prescriptions and Medical Records on your behalf. Should you need to cancel your appointment, a new scheduled appointment must be made within 10 business days or a $25.00 Fee will be charged/billed directly to you. I acknowledge that I have been made available a copy of each: CLIENT PATIENT HANDOUTS *SUPPLIER STANDARDS-Full text of standards may be found at: http://ecfr.gpoaccess.gov HIPAA PRIVACY STANDARDS PATIENT RIGHTS AND RESPONSIBILITIES CARE/USE/PRODUCT WARRANTY COVERAGE PRODUCT SAFETY: Your new products meet the specifications of your current prescription/referral. Have been checked for structural safety. All manufacturer guidelines arefollowed. Our staff may need to reach you to update records, for follow up of your last Date of Service and/or to schedule appointments. EMERGENCY &PERMISSION TO CONTACT: I, authorize A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. to share information, when necessary, with: NAME *
First Middle Last RELATIONSHIP * PHONE * *If you cannot reach us during our regular business hours, please call(954) 978-8287 and leave a message. We will return your call by the end of the next business day. I have read and understand the Store Policy, Financial Responsibility and Permission to Contact: PLEASE PRINT NAME AND SIGNATURE BELOW. PLEASE PRINT NAME: * Signature of Insured/Authorized Representative (Relationship to Insured) * DATE OF SERVICE: *
Date Format: MM slash DD slash YYYY SUPPLIER STANDARDS:
The products and/or services provided to you by A FITTING EXPERIENCE MASTECTOMY SHOPPE, INC. are subject to the Supplier Standards contained in the Federal regulation shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern post-mastectomy products suppliers and operational matters. The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. We will furnish you a written copy of these standards upon request.