Patient Agreement & Consent
Request for Equipment, Supplies and Services
The person ordering and using this website, being the named patient, his/her guardian or representative payee, understands that by ordering from this website, this Patient Agreement & Consent, the user desires to obtain specific equipment, supplies and services from BELLKINS PAPs, LLC, for rent or purchase, as prescribe by his/her treating Physician. The user also acknowledges that he/she is under the supervision and control of his/her attending physician and that no diagnosis or prescriptive orders would come from BELLKINS PAPs, LLC. The user, as or on behalf of the patient, has discussed with the attending physician the possible increased risks associated with any in-home care, including the possibilities of delays in receiving treatment for life threatening conditions as a result of being outside of the hospital setting.
Records Release
The user, as or on behalf of the named patient, hereby authorize his/her healthcare providers and payors to rely on this Patient Agreement & Consent, without the need for a separate authorization, to release the specified information for treatment, payment and health care operations to BELLKINS PAPs, LLC.
Assignment of Benefits
I, the user, hereby authorize and release BELLKINS PAPs, LLC to bill my insurance and/or Medicare on my behalf for the costs of any equipment, supplies and services provided to me. Further, the user authorizes and request my insurance carrier to pay directly to BELLKINS PAPs, LLC the amount due to me under the terms of my policy, as a result of products and/or services rendered to me. I understand that I am financially responsible for any claim denial, deductible, co-payment, takebacks and any related late/finance charges of 1.5% per month, fees associated with collection cost and reasonable attorney fees and agree to make payment at the time of service. I understand that if my account is sent to collections, I am responsible for any out of network insurance adjustments that have previously been applied to my account. I understand if I do not have insurance coverage or my insurance lapses, I will be responsible for the full amount billed, including any late/finance charges of 1.5% per month assessed, as well as any fees associated with collection costs including reasonable attorney fees. This Patient Agreement & Consent may be used in lieu of any signatures on the “Request for Payment” HCFA-1500and/or any other health insurance claim forms requiring a signature and therefore is an extension of those forms.
NOTICE OF PRIVACY PRACTICES
The user understands his/her rights and responsibilities under the HIPAA (NPP) guidelines. The user also understands his/her right to request a copy of the NOTICE OF PRIVACY PRACTICES at any time. NOTICE OF PRIVACY PRACTICES can also be found published on our website at https://www.bellkins.com/hippa-npp
Patient Agreement & Consent
Request for Equipment, Supplies and Services
The person ordering and using this website, being the named patient, his/her guardian or representative payee, understands that by ordering from this website, this Patient Agreement & Consent, the user desires to obtain specific equipment, supplies and services from BELLKINS PAPs, LLC, for rent or purchase, as prescribe by his/her treating Physician. The user also acknowledges that he/she is under the supervision and control of his/her attending physician and that no diagnosis or prescriptive orders would come from BELLKINS PAPs, LLC. The user, as or on behalf of the patient, has discussed with the attending physician the possible increased risks associated with any in-home care, including the possibilities of delays in receiving treatment for life threatening conditions as a result of being outside of the hospital setting.
Records Release
The user, as or on behalf of the named patient, hereby authorize his/her healthcare providers and payors to rely on this Patient Agreement & Consent, without the need for a separate authorization, to release the specified information for treatment, payment and health care operations to BELLKINS PAPs, LLC.
Assignment of Benefits
I, the user, hereby authorize and release BELLKINS PAPs, LLC to bill my insurance and/or Medicare on my behalf for the costs of any equipment, supplies and services provided to me. Further, the user authorizes and request my insurance carrier to pay directly to BELLKINS PAPs, LLC the amount due to me under the terms of my policy, as a result of products and/or services rendered to me. I understand that I am financially responsible for any claim denial, deductible, co-payment, takebacks and any related late/finance charges of 1.5% per month, fees associated with collection cost and reasonable attorney fees and agree to make payment at the time of service. I understand that if my account is sent to collections, I am responsible for any out of network insurance adjustments that have previously been applied to my account. I understand if I do not have insurance coverage or my insurance lapses, I will be responsible for the full amount billed, including any late/finance charges of 1.5% per month assessed, as well as any fees associated with collection costs including reasonable attorney fees. This Patient Agreement & Consent may be used in lieu of any signatures on the “Request for Payment” HCFA-1500and/or any other health insurance claim forms requiring a signature and therefore is an extension of those forms.
NOTICE OF PRIVACY PRACTICES