Patient Terms of Agreement

NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Section 1

As a customer of Strive Medical, you are entitled to certain services provided under the direction of your physician. In the course of providing these services to you, we may receive and exchange medical information necessary in the continuation of care. Federal law requires that we protect the privacy of your medical information, which includes, but may not be limited to, information that identifies you and relates to your past, present or future health or condition, the provision of health care to you, or payment for services received by you. Strive Medical may exchange Protected Health Information (PHI) with other companies (Business Associates) to assist in providing these services to you. Federal Law requires that we provide you with this notice to disclose our privacy policy and our legal duties regarding your medical information. This notice explains how, when, and why Strive Medical uses and discloses your medical information. We may change our privacy practices and the terms of this notice at any time. Changes will be effective for all of your PHI. If the privacy practices change, we will mail you a new notice of privacy practices that incorporates any changes within sixty (60) days. Certain uses and disclosures do not require your written permission. Strive Medical may use and disclose your medical information without your written permission for the following purposes: For treatment: to obtain payment for treatment; for health care operations; to you and your personal representative; when a disclosure is required by law: to Business Associates.

For other uses and disclosures permitted by law such as:

  • To public health authorities for public health purposes;
  • To state agencies handling cases of abuse, neglect, or domestic violence;
  • To a government agency authorized to oversee the health care system or government programs:
  • To comply with legal proceedings, such as a court or administrative order or a subpoena
  • To law enforcement officials for limited law enforcement purposes
  • To a coroner, medical examiner, or funeral director about a deceased person:
  • To an organ procurement organization in limited circumstances:
  • To avert a serious threat to your health or safety or the health or safety of others;
  • To military authorities if you are a member of the armed forces or a veteran of the armed forces;
  • To federal officials for lawful intelligence, counterintelligence, and other national security purposes:
  • To an executor or administrator of your estate; and
  • To any other persons and/or entities authorized under law to receive medical information.

ALL OTHER USES AND DISCLOSURES REQUIRE YOUR PRIOR WRITTEN PERMISSION

For any other use or disclosure of your medical information, Strive Medical must have your written permission. You may cancel your written permission for the use and disclosure of any or all of your medical information, however we may complete any action initiated prior to revocation and which rely on release/exchange of PHI for completion.

FILING COMPLAINTS AND/OR CONCERNS

Section 2

How to File a Complaint or Concern: If you or a family member feels that there is a need to file a complaint or concern against Strive Medical for any reason, you may do so by mailing a letter to the corporate office at 5800 Campus Circle Drive E Ste. 100B, Irving, TX 75063. You may also submit a complaint or concern via the Strive website.

PATIENT RIGHTS AND RESPONSIBILITIES

Section 3

You may make a written request to us to do one or more of the following concerning your PHI received by us or our Business Associates:

Patient Rights:

  1. You will 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.
  2. You will 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.
  3. You will receive information about the scope of services that the organization will provide and specific limitations on those services.
  4. You will participate in the development and periodic revision of the plan of care. You can refuse care or treatment after the consequences of refusing care or treatment are fully presented.
  5. Be informed of client/patient rights under state law to formulate an Advanced Directive, if applicable.
  6. You will have your property and person treated with respect, consideration, and recognition of client/patient dignity and individuality
  7. You will be able to identify visiting personnel members through proper identification.
  8. You will be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of client/patient property.
  9. You will be able to 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.
  10. You will have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated.
  11. Your confidentiality and privacy of all information contained in the client/patient record and of Protected Health Information will be maintained.
  12. You will be advised on agency’s policies and procedures regarding the disclosure of clinical records. Your records will only be shared with those you have given consent to review.
  13. You will be able to choose a health care provider, including choosing an attending physician, if applicable
  14. You will receive appropriate care without discrimination in accordance with physician orders, if applicable.
  15. You will be informed of any financial benefits when referred to an organization.
  16. You will be fully informed of your responsibilities.
  17. You will have your property and person treated with respect, consideration, and recognition of your dignity and individuality
  18. Choose a health care provider, including choosing an attending physician
  19. You will receive appropriate care without discrimination in accordance with physician orders

Patient Responsibilities:

  1. You are responsible to inform a Strive Medical Representative of any changes in insurances
  2. You are responsible to inform a Strive Medical Representative of any changes in address or other contact information
  3. You are responsible to inform a Strive Medical Representative of any products that you received that are incorrect, damaged or missing
  4. You are responsible for the payments of all co-pays and deductibles You are responsible to adhere to your physicians prescriptions

Although Strive Medical will utilize its best efforts to comply with your request, we may legally deny your request in certain circumstances. We will notify you of the reason for the denial and you will get a chance to respond. We may not deny a request to communicate with you in confidence by a different means or location if the current means or location used by us endangers you. Your request to communicate by a different means or location must be in writing, include a statement that discloses how the current means of communication could endanger you. Specifically state the requested means or location by which you would like us to communicate with you in the future. If you feel your privacy rights have been violated, you may file a written complaint to the below address or submit a complaint via our website.

  • Address: Strive Medical 5800 Campus Circle . Dr. E Ste. 100 B • Irving, TX 75063
  • Telephone Number: 1-888-771-9229
  • Website: www.strivemedical.com

PATIENT RIGHTS AND RESPONSIBILITIES

Section 3

You may make a written request to us to do one or more of the following concerning your PHI received by us or our Business Associates:

Patient Rights:

  1. You will 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.
  2. You will 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.
  3. You will receive information about the scope of services that the organization will provide and specific limitations on those services.
  4. You will participate in the development and periodic revision of the plan of care. You can refuse care or treatment after the consequences of refusing care or treatment are fully presented.
  5. Be informed of client/patient rights under state law to formulate an Advanced Directive, if applicable.
  6. You will have your property and person treated with respect, consideration, and recognition of client/patient dignity and individuality
  7. You will be able to identify visiting personnel members through proper identification.
  8. You will be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of client/patient property.
  9. You will be able to 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.
  10. You will have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated.
  11. Your confidentiality and privacy of all information contained in the client/patient record and of Protected Health Information will be maintained.
  12. You will be advised on agency’s policies and procedures regarding the disclosure of clinical records. Your records will only be shared with those you have given consent to review.
  13. You will be able to choose a health care provider, including choosing an attending physician, if applicable
  14. You will receive appropriate care without discrimination in accordance with physician orders, if applicable.
  15. You will be informed of any financial benefits when referred to an organization.
  16. You will be fully informed of your responsibilities.
  17. You will have your property and person treated with respect, consideration, and recognition of your dignity and individuality
  18. Choose a health care provider, including choosing an attending physician
  19. You will receive appropriate care without discrimination in accordance with physician orders

ASSIGNMENTS OF BENEFITS

Section 4

I request that payment of authorized insurance benefits, including Medicare, if I am a Medicare beneficiary, be made on my behalf to the organization listed for any equipment or services provided to me by that organization. I authorize the release of any medical or other information necessary to determine these benefits payable for related equipment or services to the organization, the Health Care Financing Administration, my insurance carrier or other medical entity. A copy of this authorization will be sent to the Health Care Financing Administration, my insurance company or other entity if requested. The original authorization will be kept on file by the organization. I understand that I am financially responsible to the organization for any charges not covered by my health care benefits. It is my responsibility to notify the organization of any changes in my health care coverage. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that I am accepting financial responsibility as explained above for all payment for products received. This acknowledgement is required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made aware of my privacy rights. I understand that I am responsible for any deductibles or copays I have at the time of delivery.

MEDICAL SUPPLY WARRANTIES AND RETURNS

Section 5

Your physician has recently placed an order with Strive Medical for medical supplies. You should be receiving these supplies within the next few days. As soon as you receive your products, please match them with the products listed on the packing invoice to ensure you have received everything documented on the packing slip. If you did not receive all of your product, too much product or found that the product was damaged or defective, please contact Strive Medical within 48 hours of the delivery receipt Strive Medical will replace any items that were damaged or defective upon opening. If the product is undamaged and not defective, Strive Medical cannot accept a returned product that is opened or not in its original packaging. Strive Medical may require a return fee for product received 30 days after the return request. Note: most supply products have an expiration date printed on the product packaging. Please verify that the product has not expired before using. Do not use a product that has passed its expiration date. At Strive Medical we value you as a customer and hope that we can provide 100% satisfaction.

MEDICAL SUPPLIER STANDARDS

Section 6

  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 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 nonprocurement programs.
  5. 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.
  6. 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.
  7. A supplier must maintain a physical facility on an appropriate site.
  8.  A supplier must permit HCFA, or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards. The supplier location must be accessible to beneficiaries during business hours, and must maintain a visible sign and posted hours of operation.
  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 or cell phone 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 must agree not to initiate telephone contact with beneficiaries with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business.
  12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.
  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 supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
  17.  A supplier must disclose to the government 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 HCFA 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. Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation date-May 4, 2009.
  27.  A supplier must obtain oxygen from a state-licensed oxygen supplier.
  28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f).
  29. DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.
  30. DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.

SCOPE OF SERVICES

Section 7

Strive Medical is a national mail-order supply company. Strive Medical specializes in wound care products, catheters and incontinence products. Strive Medical will not provide products or services outside of our scope of service. Strive Medical is not an emergency response organization

EMERGENCY PREPAREDNESS

Section 8

  1. In the event of a disaster the Compliance Officer will determine if the physical site at the organization is safe (i.e., in the event of earthquake, tornado, hurricane, etc.) and habitable. When power is out at the organization the Compliance Officer will contact the electric company for time frame for resolution. An emergency alternate site may be used. The alternate sites may be allowing employees to work remotely from home.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.
  2.  The Compliance Officer will determine which employees, if any, need to respond. Those employees will be requested to report to the organization. In the event the organization is inhabitable the Compliance Officers’ home or alternate site will serve as communication headquarters.
  3.  will respond to individual patients on an as-needed basis depending upon the accessibility of the affected area.
  4. It is the policy of the company to establish and maintain open communication with the local office of FEMA. Our staff should be informed as to the local provisions from the local FEMA office for the emergency planning.
  5.  will be contacted in the following order during an emergency if they are effected by the disaster or emergency: a. Patients who are due to receive supplies that day b. Patients who are due to receive a phone call regarding reorder of their supplies
  6. 911 services will be utilized as needed for emergency care/services for clients/patients and personnel.
  7. The Compliance Officer will evaluate the effectiveness of the plan whenever it has had to be implemented. A disaster drill is conducted annually in the event the plan has not been used this will be used to evaluate the plan.
  8. The disaster plan will be reviewed with all employees during orientation and annually.

Emergency Phone Numbers are as follows:

  • 911 (local law enforcement agencies)
  • 800-621-3362 (FEMA)
  • 800-733-2767 (Red Cross)Emergency Phone

If you have a life-threatening emergency, please contact 911 or visit your local emergency room. If you call Strive Medical after hours, please a leave a voicemail with your name and date of birth and a Strive representative will contact you within the next 24-48 hours.

PRODUCT SAFETY AND USE INSTRUCTIONS

Section 9

You will receive product safety and usage instructions from the manufacturer for every product you receive. If you do not receive product safety and usage instructions for any item that you receive, contact a Strive Medical Representative immediately.

BILLING AND COLLECTIONS POLICIES

Section 10

Once you have received supplies or services from Strive Medical and Strive Medical has received all necessary documentation, Strive will bill your insurance carrier on file for all products and services received. Strive Medical will adhere to the Explanation of Benefits received from your insurance carrier. This may include, billing your secondary insurance carrier for the remaining balance or dropping the remaining balance to you for payment. You will be responsible for any and all charges for supplies or services received that are not covered by your insurance plan, any charges for co-insurance and/or for deductibles. If your insurance plan has terminated or if you no longer have insurance at the time the claims are processed, you will be responsible for the full amount of the charges. Strive Medical sends statements once a month for all patients who have a balance. Balances should be paid in full within 30 days of receipt of the statement unless other arrangements have been made with a Strive Medical Representative. Any balances that are not paid within 90 days can and will be forwarded to a third-party collection agency. At this time, a late fee will be applied as well.

MISSION STATEMENT

Section 11

The mission of Strive Medical is to provide every patient and every customer with quality healthcare services through commitment, dedication and promptness as we feel that this is our responsibility and duty as a premier medical supply provider. We are committed to give our patients the best customer service and the best products available in today’s healthcare market. Every Strive Medical team member follows this brand of commitment to fulfill the needs of our patients and to assist the healthcare providers reach a common goal in each patient’s plan of care. At Strive Medical, our belief is, the patient always comes first. You will find this to be the consistent trend throughout our organization as these values permeate throughout the Strive Medical Team. We truly strive to help patients find their freedom and independence.

ACCREDITATION

Section 12

Strive Medical is an accredited organization. Strive’s accrediting body is the Accreditation Commission for Health Care (ACHC). They can be contacted via their website at https://www.achc.org or by phone at 855-937-2242.

*Spanish version is available upon request, please contact 888-771-9229 for assistance.*