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Rights, Responsibilities, Rental & Sales Agreement

Company when used in the agreement, refers to MedVantage. Patient refers to the person receiving medical equipment & supplies. TITLE to the rental equipment & all parts shall remain with the Company, unless equipment is purchased & paid in full. Patient must promptly notify Company of rental equipment malfunctions or defects & allow Company representatives to enter their premises to perform REPAIR & SERVICE. Patient agrees that said equipment will be used solely by Patient and no other persons without the written consent of Company. Company shall not insure or be responsible to patient or caregiver for any PERSONAL INJURY OR PROPERTY DAMAGE related to any equipment, including that caused by use or improper functioning of equipment, the act or omission of any third party, or by any criminal act or activity, fire or act of God. Company may impose a monthly service charge of 1 % of the unpaid balance. Sales RETURNS may be accepted in unopened packages &/or saleable condition with in three (3) days from date of original invoice with proof of purchase. Due to health department regulations, no merchandise may be accepted for return if worn next to the skin, food product, used for sanitary or hygienic purposes or if it is disposable (electrodes, wipes, creams, batteries, etc.). Special order items will require a deposit & are non-returnable. Company maintains 24-hour availability by telephone, pager or answering service. Patient is responsible for monitoring supply levels. If a life- threatening MEDICAL EMERGENCY arises the patient or caregiver should contact their local emergency services number for assistance. Patient will be communicated with in a way they can understand. Those wishing to express their concerns or comments or review, restrict or revokeconsent on their files should contact the Company during regular business hours. Your COMMENTS will be reviewed & appropriate action taken by the Company, in its discretion. Patient retains the right to refuse Company services & assumes responsibility for any consequences relating to REFUSAL of any service ordered delivered to the patient by a healthcare professional. Patient may participate in all decisions regarding service, including admission, plan of service, discharge transfer & referral and will receive experimental treatment only with a voluntary informed consent. Patient personal healthcare information listed on the reverse side will be kept CONFIDENTIAL by Company and only used for healthcare operations, services & payment purposes (A complete copy of this policy is available for review in our office). In the interest of health & safety, Company retains the RIGHT TO REFUSE DELIVERY of service at any time; however, the Company does not discriminate. Patient has a right to respect, dignity, privacy, choice, informed consent, special communication needs, participation in the care planning process, adequate care & services, appropriate assessment and management of pain, description & charges of those services available and payment for them. Patient has the right to be free from mental physical abuse. Patient agrees to NOTIFY Company of any MEDICAL STATUS change such as doctor’s prescription, advance directives being in place or changed, acquiring an infection requiring hospitalization or MD visit, change of residence or insurance coverage. Company is privately-owned and any financial benefits of referrals made by the Company will be disclosed to the patient. Company employees and agents always carry identification. Patient & Company agree to go to arbitration if a disagreement arises between the parties. Patient shall hold harmless and indemnify Company, its officers, directors, sales agents, employees, agents, successors and assigns, and of any person, film or corporation now or hereafter acting as agent for the Company in any capacity from and against any and all liabilities, costs, damage expenses, and attorneys’ fees of any kind, character or nature, in connection with, or arising out of, resulting from or attributable to, or caused directly or indirectly by: (a) Patient’s failure to promptly perform any of its obligations under the provisions of the Lease or Purchase, or (b) injury to person or property resulting from or based upon the actual or alleged use, operation, delivery or transportation of any or all the equipment or its location or condition, or (c) the release of any and all medical information to or by MedVantage, to process any and/or all insurance claims, or (d) inadequacy of the Equipment, or any part thereof, for any purpose or any deficiency or defect therein or the use or maintenance thereof or an y repairs, servicing or adjustments thereto or any delay in providing or failure to provide any thereof or any interruption or loss of service or use thereof.

Patient Health Information-Privacy Notice

Please note that we maintain paper & electronic files that may contain private information about you that may include, but not limited to your name, address, phone number, contact person, height & weight, diagnosis, prognosis, physician(s), prescriptions, plans of service & treatment, vital signs & other clinical impressions, insurance coverage(s), equipment rented & purchased from us, credit card number(s), social security numbers, dates of service, etc. We release, transfer & disclose the above information to third parties to facilitate appropriate provision & review of services & billing for our clients of record. These files are legal documents & are also used for education, evaluating the performance of our organization, marketing & planning purposes. We have measures in place to protect patient health information as required by law. These measures include, but are not limited to, security precautions being in place in our buildings, vehicles, billing software, transactions with government entities, vendors, consultants, surveyors, your family or appointed representative & other appropriate parties, transmission of data to third parties, telephone & wireless communications, maintenance, retention & destruction of data, etc. You have the right to amend, restrict, revoke consent to release, examine or obtain copies of the data that we have in your file & have released to others upon request. If you have questions concerning any of the above, please contact MedVantage.

The products and/or services provided to you by MedVantage 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). Upon request we will furnish you a written copy of the standards. A copy of the standards and other important information can also be found at our website at http://www.medvantageco.com.

Please visit our website at www.medvantage.com/survey and fill out our patient survey to tell us about your experience with MedVantage.

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