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HIPAA Notice of Privacy Practices


This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law.

It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by our organization, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the organization, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we may request diagnosis information from your physician to ensure the correct supplies are being provided.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for equipment or supplies coverage may require that your relevant protected health information be disclosed to the health plan to obtain approval for coverage.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of our organization. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our staff. These activities include, but are not limited to, quality assessment activities, employee reviews, and conducting or arranging for other business activities. For example, we may disclose your protected health information to accrediting agencies as part of an accreditation survey. We may also call you by name while you are at our facility. We may use or disclose your protected health information, as necessary, to contact you to check the status of your supplies.

We may use or disclose your protected health information in the following situations without your authorization, subject to all applicable legal requirements and limitations: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, Inmates, Military Activity, National Security, and Workers’ Compensation. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements.

Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or Opportunity to Object, unless required by law.

We will not use or disclose your health information for any purpose other than those identified in the previous sections without your authorization. We also will not use or disclose your PHI for our marketing purposes or for the purpose of selling your health information.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or this organization has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights: Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. You have the right to inspect and copy your health information, such as medical and billing records. We will provide you with a copy in the form and format requested where possible. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Our organization is not required to agree to a restriction that you may request. If our organization believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

We are required to agree to your request if you pay for supplies “out of pocket” and you request the information not to be communicated to your health plan for payment or health care operations purposes.

There may be instances where we are required to release this information if required by law.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, e.g., electronically. You may also find a copy of this Notice on our website,

You may have the right to have our organization amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This is a list of any disclosures we made of medical information about you for purposes other than treatment, payment, health care operations, when specifically authorized by you. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Breach of Health Information: In the case of a breach of unsecured health information, we will notify you as required by law.

Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any questions concerning, or objections to this form, please contact our Privacy Officer at

Associated companies with whom we may do business, such as an answering service or delivery service, are given only enough information to provide the necessary service to you. No medical information is provided. There may be instances where we use or disclose your medical information with business associates who provide services for us. We have a written contract with each of these associates containing terms requiring them to protect the confidentiality and security of your protected health information.

We welcome your comments: Please feel free to call us if you have any questions about how we protect your privacy. Our goal is always to provide you with the highest quality services.

This notice was published and becomes effective on/or before September 2013.


We believe that all clients/patients receiving services from HDIS should be informed of their rights. Therefore, you are entitled to:

  • Be fully informed in advance about care/service to be provided, including the disciplines that furnish care and the frequency of visits, as well as any modifications to the plan of care.
  • Be informed, both orally and in writing, in advance of care being provided, of the charges, including payment for care/service expected from third parties and any charges for which the client/patient will be responsible.
  • Receive information about the scope of services that the organization will provide and specific limitations on those services.
  • Participate in the development and periodic revision of the plan of care.
  • Refuse care or treatment after the consequences of refusing care or treatment are fully presented.
  • Be informed of client/patient rights under state law to formulate an Advanced Directive, if applicable.
  • Have one’s property and person treated with respect, consideration, and recognition of client/patient dignity and individuality.
  • Be able to identify visiting personnel members through proper identification.
  • Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of client/patient property.
  • Voice grievances/complaints regarding treatment or care, lack of respect of property or recommend changes in policy, personnel, or care/service without restraint, interference, coercion, discrimination, or reprisal.
  • Have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated.
  • Confidentiality and privacy of all information contained in the client/patient record and of Protected Health Information.
  • Be advised on agency’s policies and procedures regarding the disclosure of clinical records.
  • Choose a health care provider, including choosing an attending physician, if applicable.
  • Receive appropriate care without discrimination in accordance with physician orders, if applicable.
  • Be informed of any financial benefits when referred to an organization.
  • Be fully informed of one’s responsibilities.


  • Client agrees that medical supplies will be used with reasonable care, not altered or modified, and returned in good condition.
  • Client agrees to promptly report to HDIS any malfunctions or defects in the medical supplies so that repair/ replacement can be arranged.
  • Client agrees to provide HDIS access to all medical supplies for repair/replacement, maintenance, and/or pick-up of the equipment.
  • Client agrees to use the medical supplies for the purposes so indicated and in compliance with the physician’s prescription.
  • Client agrees to keep the medical supplies in their possession and at the address, to which it was delivered unless otherwise authorized by HDIS.
  • Client agrees to notify HDIS of any hospitalization, change in customer insurance, address, telephone number, physician, or when the medical need for the supplies no longer exists.
  • Client agrees to request payment of authorized Medicare, Medicaid, or other private insurance benefits are paid directly to HDIS for any services furnished by HDIS.
  • Client agrees to accept all financial responsibility for medical supplies furnished by HDIS.
  • Client agrees to pay for the replacement cost of any equipment damaged, destroyed, or lost due to misuse, abuse or neglect.
  • Client agrees not to modify the medical supplies without the prior consent of HDIS.
  • Client agrees that any authorized modification shall belong to the titleholder of the medical supplies unless the supplies are purchased and paid for in full.
  • Client agrees that title to the rental equipment and all parts shall remain with HDIS at all times unless equipment is purchased and paid for in full.
  • Client agrees that HDIS shall not insure or be responsible to the patient for any personal injury or property damage related to any equipment; including that caused by use or improper functioning of the equipment; the act or omission of any other third party, or by any criminal act or activity, war, riot, insurrection, fire or act of God.
  • Client understands that HDIS retains the right to refuse delivery of service to any client at any time.
  • Client agrees that any legal fees resulting from a disagreement between the parties shall be borne by the unsuccessful party in any legal action taken.

When the client/patient is unable to make medical or other decisions, the family should be consulted for direction.


HDIS adheres to the following standards as required by the Centers for Medicare and Medicaid Service:

  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. 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.
  4. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
  5. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
  6. 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.
  7. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards.
  8. 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 mobile communications devices is prohibited.
  9. 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.
  10. A supplier is prohibited from direct solicitation to Medicare beneficiaries.

    For complete details on this prohibition see 42 C.F.R. 424.57(c) (11).

  11. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.
  12. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
  13. 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.
  14. 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.
  15. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
  16. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
  17. 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.
  18. 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.
  19. Complaint records must include: the name, address, telephone number, a summary of the complaint, and any actions taken to resolve it.
  20. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.
  21. 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).
  22. All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
  23. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
  24. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
  25. Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c).
  26. A supplier must obtain oxygen from a state-licensed oxygen supplier.
  27. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f).
  28. A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers.
  29. 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.


At HDIS, we want to make sure that your home medical treatment is done conveniently and safely. These pages are written to give our client/patients some easy and helpful tips on how to make the home safe for home care.

Fire Safety and Prevention

  • Smoke detectors should be installed in your home. Make sure you check the batteries at least once a year.
  • If appropriate, you may consider carbon monoxide detectors as well. Ask your local fire department if you should have one in your home.
  • Have a fire extinguisher in your home, and have it tested regularly to make sure it is still charged and in working order.
  • Have a plan for escape in the event of a fire. Discuss this plan with your family.
  • If you use oxygen in your home, make sure you understand the hazards of smoking near oxygen. Review the precautions. If you aren’t sure, ask your oxygen provider what they are.
  • If you are using electrical medical equipment, make sure to review the instruction sheets for that equipment.

Electrical Safety

  • Make sure that all medical equipment is plugged into a properly grounded electrical outlet.
  • If you have to use a three-prong adapter, make sure it is properly installed by attaching the ground wire to the plug outlet screw.
  • Use only good quality outlet “extenders” or “power strips” with internal Circuit breakers. Don’t use cheap extension cords.

Safety in the Bathroom

Because of the smooth surfaces, the bathroom can be a very dangerous place, especially for persons who are unsteady.

  • Use non-slip rugs on the floor to prevent slipping.
  • Install a grab-bar on the shower wall, and non-slip footing strips inside the tub or shower.
  • Ask your medical equipment provider about a shower bench you can sit on in the shower.
  • If you have difficulty sitting and getting up, ask about a raised toilet seat with arm supports to make it easier to get on and off the commode.
  • If you have problems sensing hot and cold, you should consider lowering the temperature setting of your water heater so you don’t accidentally scald yourself without realizing it.

Safety in the Bedroom

It’s important to arrange a safe, well-planned and comfortable bedroom since a lot of your recuperation and home therapy may occur there.

  • Ask your home medical provider about a hospital bed. These beds raise and lower so you can sit up, recline, and adjust your knees. A variety of tables and supports are also available so you can eat, exercise, and read in bed.
  • Bed rails may be a good idea, especially if you have a tendency to roll in bed at night.
  • If you have difficulty walking, inquire about a bedside commode so you don’t have to walk to the bathroom to use the toilet.
  • Make sure you can easily reach the light switches, and other important things you might need through the day or night.
  • Install night-lights to help you find your way in the dark at night.
  • If you are using an IV pole for your IV or enteral therapy, make sure that all furniture, loose carpets, and electrical cords are out of the way so you do not trip and fall while walking with the pole.

Safety in the Kitchen

Your kitchen should be organized so you can easily reach and use the common items, especially during your recuperation while you are still a bit weak:

  • Have a friend or health care worker remove all common small appliances and utensils from cabinets, and place them on your counters where you can easily use them.
  • Have a chair brought into the kitchen to the counter work area if you have difficulty standing.
  • Make sure you are careful lifting pots and pans. Not only might they be hot, but they can be heavy as well. Use padded mitts to firmly grasp pans and pots on both sides.
  • Ask your kitchen or hardware store about utensils for manually impaired or arthritic persons, including:
    • Basic electric can openers
    • Bottle and jar openers
    • Large-handled utensils
  • When working at your stove, be very careful that intravenous, tube feeding tubing, or oxygen tubing do not hang over the heat. They can be flammable.

Getting Around Safely

If you are now using assistant devices for ambulating (walking), here are some key points:

  • Install permanent or temporary guardrails on stairs to give you additional support if you are using a cane or are unsteady.
  • If you are using a walker, make sure that furniture and walkways are arranged to give you enough room.
  • If you are using a walker or wheelchair, you may need a ramp for getting into or out of the house. Ramps can be purchased ready-made, or may be constructed for you. Talk to your home medical equipment provider about available options.

What To Do If You Get Hurt…

In case of emergency, contact:

Fire, Police, Ambulance: 911

HDIS Phone: 1-800-269-4663

If you have any questions about safety that aren’t in this booklet, please call us and we will be happy to give you recommendations for your individual needs.


Many falls can be prevented. By making some changes, you can lower your chances of falling. Four things YOU can do to prevent falls:

  1. Begin a regular exercise program

    Exercise is one of the most important ways to lower your chances of falling. It makes you stronger and helps you feel better. Exercises that improve balance and coordination (like Tai Chi) are the most helpful. Lack of exercise leads to weakness and increases your chances of falling. Ask your doctor or health care provider about the best type of exercise program for you.

  2. Have your health care provider review your medicines

    Have your doctor or pharmacist review all the medicines you take, even over–the–counter medicines. As you get older, the way medicines work in your body can change. Some medicines, or combinations of medicines, can make you sleepy or dizzy and can cause you to fall.

  3. Have your vision checked

    Have your eyes checked by an eye doctor at least once a year. You may be wearing the wrong glasses or have a condition like glaucoma or cataracts that limits your vision. Poor vision can increase your chances of falling.

  4. Make your home safer

    About half of all falls happen at home.

To make your home safer:

  • Remove things you can trip over (like papers, books, clothes, and shoes) from stairs and places where you walk.
  • Remove small throw rugs or use double-sided tape to keep the rugs from slipping.
  • Keep items you use often in cabinets you can reach easily without using a step stool.
  • Have grab bars put in next to your toilet and in the tub or shower.
  • Use non-slip mats in the bathtub and on shower floors.
  • Improve the lighting in your home. As you get older, you need brighter lights to see well. Hang light-weight curtains or shades to reduce glare.
  • Have handrails and lights put in on all staircases.
  • Wear shoes both inside and outside the house. Avoid going barefoot or wearing slippers.



Each year, thousands of older Americans fall at home. Many of them are seriously injured, and some are disabled. In 2010, 2.3 million nonfatal fall injuries among older adults were treated in emergency departments and more than 662,000 of these patients were hospitalized.

Falls are often due to hazards that are easy to overlook but easy to fix. This checklist will help you find and fix those hazards in your home.

The checklist asks about hazards found in each room of your home. For each hazard, the checklist tells you how to fix the problem. At the end of the checklist, you’ll find other tips for preventing falls.


Look at the floor in each room.

Q: When you walk through a room, do you have to walk around furniture?

Ask someone to move the furniture so your path is clear.

Q: Do you have throw rugs on the floor?

Remove the rugs or use double-sided tape or a non-slip backing so the rugs won’t slip.

Q: Are there papers, books, towels, shoes, magazines, boxes, blankets, or other objects on the floor?

Pick up things that are on the floor. Always keep objects off the floor.

Q: Do you have to walk over or around wires or cords (like lamp, telephone, or extension cords)?

Coil or tape cords and wires next to the wall so you can’t trip over them. If needed, have an electrician put in another outlet.


Look at the stairs you use both inside and outside your home.

Q: Are there papers, shoes, books, or other objects on the stairs?

Pick up things on the stairs. Always keep objects off stairs.

Q: Are some steps broken or uneven?

Fix loose or uneven steps.

Q: Are you missing a light over the stairway?

Have an electrician put in an overhead light at the top and bottom of the stairs.

Q: Do you have only one light switch for your stairs (only at the top or at the bottom of the stairs)?

Have an electrician put in a light switch at the top and bottom of the stairs. You can get light switches that glow.

Q: Has the stairway light bulb burned out?

Have a friend or family member change the light bulb.

Q: Is the carpet on the steps loose or torn?

Make sure the carpet is firmly attached to every step, or remove the carpet and attach non-slip rubber treads to the stairs.

Q: Are the handrails loose or broken? Is there a handrail on only one side of the stairs?

Fix loose handrails or put in new ones. Make sure handrails are on both sides of the stairs and are as long as the stairs.


Look at your kitchen and eating area.

Q: Are the things you use often on high shelves?

Move items in your cabinets. Keep things you use often on the lower shelves (about waist level).

Q: Is your step stool unsteady?

If you must use a step stool, get one with a bar to hold on to. Never use a chair as a step stool.


Look at all your bathrooms.

Q: Is the tub or shower floor slippery?

Put a non–slip rubber mat or self-stick strips on the floor of the tub or shower.

Q: Do you need some support when you get in and out of the tub or up from the toilet?

Have a carpenter put grab bars inside the tub and next to the toilet.


Look at all your bedrooms.

Q: Is the light near the bed hard to reach?

Place a lamp close to the bed where it’s easy to reach.

Q: Is the path from your bed to the bathroom dark?

Put in a night-light so you can see where you’re walking. Some night-lights go on by themselves after dark.

Other Things You Can Do to Prevent Falls

Exercise regularly. Exercise makes you stronger and improves your balance and coordination.

Have your doctor or pharmacist look at all the medicines you take, even over-the-counter medicines. Some medicines can make you sleepy or dizzy.

Have your vision checked at least once a year by an eye doctor. Poor vision can increase your risk of falling.

Get up slowly after you sit or lie down.

Wear shoes both inside and outside the house. Avoid going barefoot or wearing slippers.

Improve the lighting in your home. Put in brighter light bulbs. Florescent bulbs are bright and cost less to use.

It’s safest to have uniform lighting in a room. Add lighting to dark areas. Hang lightweight curtains or shades to reduce glare.

Paint a contrasting color on the top edge of all steps so you can see the stairs better. For example, use a light color paint on dark wood.

Other Safety Tips

Keep emergency numbers in large print near each phone.

Put a phone near the floor in case you fall and can’t get up.

Think about wearing an alarm device that will bring help in case you fall and can’t get up.


This information has been provided by HDIS to help you plan your actions in case there is a natural disaster where you live. Many areas of the United States are prone to natural disasters like hurricanes, tornadoes, floods, and earthquakes.

Every client/patient receiving care or services in the home should think about what they would do in the event of an emergency.

Our goal is to help you plan so that we can try to provide you with the best, most consistent service we can during the emergency.

Know What to Expect

If you have recently moved to this area, take the time to find out what types of natural emergencies have occurred in the past, and what types might be expected.

Find out what, if any, time of year these emergencies are more prevalent.

Find out when you should evacuate, and when you shouldn’t.

Your local Red Cross, local law enforcement agencies, local news and radio stations usually provide excellent information and tips for planning.

Know Where to Go

One of the most important pieces of information you should know is the location of the closest emergency shelter.

These shelters are opened to the public during voluntary and mandatory evacuation times. They are usually the safest place for you to go, other than a friend or relative’s home in an unaffected area.

Know What to Take with You

If you are going to a shelter, there will be restrictions on what items you can bring with you. Not all shelters have adequate storage facilities for medications that need refrigeration.

We recommend that you call ahead and find out which shelter in your area will let you bring your medications and medical supplies, in addition, let them know if you will be using medical equipment that requires an electrical outlet.

Bring all your medications and supplies with you to the shelter.

Reaching HDIS if There Are No Phones

How do you reach us during a natural emergency if the phone lines don’t work? Cellular phones frequently work even when the regular land phone lines do not.

If you have no way to call, you can try to reach us by having someone you know call us from his or her cellular phone. Many times cellular phone companies set up communication centers during natural disasters. If one is set up in your area, you can ask them to contact us.

An Ounce of Prevention...

We would much rather prepare you for an emergency ahead of time, let us know where to send you the supplies you need.

To do this, we need for you to give us as much information as possible before the emergency. We may ask you for the name and phone number for the people you are staying with during the emergency. We may ask you where you will go if an emergency occurs. Will you go to a shelter, or a relative’s home? If your doctor has instructed you to go to a hospital, which one is it?

Having the address of your evacuation site, if it is in another city, will allow us to service your needs efficiently.

Helpful Tips

  • Get a cooler and ice or freezer gel-packs to transport your medication.
  • Get all of your medication information and teaching modules together and take them with you if you evacuate.
  • Pack one week’s worth of supplies in a plastic-lined box or waterproof tote bag or tote box. Make sure the seal is watertight.
  • Make sure to put antibacterial soap and paper towels into your supply kit.
  • If possible, get waterless hand disinfectant from HDIS or from a local store. It comes in very handy if you don’t have running water.
  • When you return to your home, contact HDIS so we can see what supplies you need.

For More information

There is much more to know about planning for and surviving during a natural emergency or disaster.

To be ready for an emergency, contact your local American Red Cross or Emergency Management Services agency.


Authorization/Consent for Care/Service:

I have been informed of the home care options available to me and of the selection of providers from which I may choose. I authorize HDIS under the direction of the prescribing physician, to provide home medical equipment, supplies and services as prescribed by my physician.

Assignment of Benefits/Authorization for Payment:

I hereby assign all benefits and payments to be made directly to HDIS for any home medical equipment, supplies and services furnished to me in conjunction with my home care. I authorize HDIS to seek such benefits and payments on my behalf. It is understood that, as a courtesy, HDIS will bill Medicare/Medicaid or other federally funded sources and other payors and insurer(s) providing coverage where available. 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 HDIS within 30 days of the event. I have been informed by HDIS of the medical necessity for the services prescribed by my physician. I understand that in the event services are deemed not reasonable and necessary, payment may be denied and that I will be fully responsible for payment.

Release of Information:

I hereby request and authorize HDIS, the prescribing physician, hospital, and any other holder of information relevant to service, to release information upon request, to HDIS, any payor source, physician, or any other medical personnel or agency involved with service. I also authorize HDIS to review medical history and payor information for the purpose of providing home health care.

Financial Responsibility:

I understand and agree that I am responsible for the payment of any and all sums that may become due for the services provided. These sums include, but are not limited to, all deductibles, co-payments, out-of-pocket requirements, and non-covered services. If for any reason and to any extent, HDIS does not receive payment from my payor source, I hereby agree to pay HDIS for the balance in full, within 14 days of receipt of invoice. All charges not paid within 30 days of the due date shall be assessed late charges. I am liable for all charges, including collection costs and all attorney costs. I am responsible for all charges regardless of my payor unless my agreement with my health plan holds me harmless.

Returned Goods:

At HDIS, we stand behind our products and services 100%. If for any reason you are not satisfied with the products you receive from us, you may return unopened packages for a full refund. Due to health regulations, we cannot accept returns on any opened packages, used items, or reusable products. Therefore, these items cannot be returned for credit. Notify HDIS if any product is defective. In the case of defective product, an exchange will be made for the defective item.

Client/Patient Handouts:

I acknowledge that I have received a copy of the Client/patient Handouts which contains Client/patient Rights and Responsibilities, Supplier Standards, Home Safety Information, HIPPA Privacy Standards, and Emergency Planning. I acknowledge that the information in the Client/patient Handouts has been explained to me and that I understand the information.

Grievance Reporting:

I acknowledge that I have been informed of the procedure to report a grievance should I become dissatisfied with any portion of my HDIS experience. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call 1-800-269-4663 and speak to the Customer Care Manager. If your complaint is not resolved to your satisfaction within 5 working days, you may initiate a formal grievance, in writing and forward it to the President. You can expect a written response within 7 working days of receipt.

You may also make inquiries or complaints about this company by calling ACHC at 919-785-1214, or Medicare at 1-800-Medicare (1-800-633-4227).

Home Health Hotline:

To further assist you, the Office of the Inspector General maintains a hotline, which offers a confidential means for reporting vital information. The Hotline can be contacted at 1-800-HHS-TIPS (1-800-447-8477).

You may also make inquiries or complaints about this company by calling your local Social Services Department and/or ACHC.


HDIS does not discriminate against any person on the basis of race, color, national origin, disability, gender or age in admission, treatment, or participation in its programs, services and activities, or in employment.

In case of questions concerning this policy, or in the event of a desire to file a complaint alleging violations of the above, please contact the HDIS Compliance Officer at:

You may also file a complaint with the Department of Social Services:

Department of Social Services

Office of Civil Rights

P.O. Box 1527

Jefferson City, MO 65102

(800) 776-8014 or (800) 877-6916 (TDD)

Non Retaliation Clause: You will not be intimidated, harassed, threatened or suffer any penalty because you file a complaint. Any penalty or reprisal against you or any other involved persons is prohibited by law.

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