"Your Local Home Oxygen Specialists"

Customer Information Handout

Welcome! Thank you for choosing Mendo-Lake Home Respiratory Services to be your medical equipment supplier. This handout provides you with information for your overall health care. Please keep this handout for reference and call our office at anytime if you have questions.

In specific, this handout shares information with you about the following:

• Our commitment in providing quality services and products
• Our grievance procedure
• Patient communication form
• Your rights and responsibilities as a customer
• Fall Risk Prevention Information
• Medicare supplier standards
• Our service, delivery and warranty policies
• Notice of privacy practices
• Local Community Resource list

We are dedicated to providing comprehensive home care services to our customers with the utmost quality and professionalism. We accept only those customers whose home health needs, as identified by the referring source, can be met by the services we offer. We not only provide quality home care products, we genuinely care for the customers we serve.

SCOPE OF SERVICES

Respiratory Equipment
• Oxygen Concentrators
• Portable Oxygen Systems
• CPAP/BiPAP Systems
• Nebulizers
• Oximeters

Geographic Coverage
Lake County/Mendocino County

Mission Statement
To be the preferred local provider of home health and institutional products by demonstrating our commitment to excellence, customer service and by delivering specialty services ensuring quality care for all patients and being a reliable partner to the health care community.

Compliance and Commitment
Mendo-Lake Home Respiratory Services is committed to complying with all federal and state regulations. If you have any questions or concerns regarding any of our activities, please contact us at the telephone number on the front of this handout. If, after speaking with us, you still feel that we are not in compliance with regulations or that fraud has occurred, you can call the Medicare Fraud Hotline at 1-800-447-8477. If you feel you have complaints about the quality of products or services provided that you have been unable to resolve with us you may contact the Joint Commission at 1-800-994-6610.

Patient Complaint Procedure
All of our customers are very important to us. So that we can resolve any problems that arise in a rapid and effective manner, we have developed the following patient grievance procedure.

1. When you have a concern, you can speak to the person delivering you equipment at the next visit.
2. If you do not want to wait to speak to the delivery person or if the issue you have involves our employee, you can call our office and speak with the manager of your servicing location.
3. If your issue cannot be solved locally you may contact the company at the number on the first page of this handout.

We have also included a Patient Communication Form on the following page that you may complete and mail to us should you wish to contact us.

MEDICARE DMEPOS SUPPLIER STANDARDS
Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).

1.A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements and cannot contract with an individual or entity to provide licensed services.

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 non-procurement 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. This standard requires that the location is 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.

8.A supplier must permit CMS, 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 reasonable 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, answering service or cell phone during posted business hours 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 contacting a Medicare beneficiary based on a physician’s oral order unless an exception applies.

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 CMS 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). Implementation Date – October 1, 2009

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.

Patient’s Bill of Rights and Responsibilities
You have the right to:
1. Service that is considerate and respectful of your person, property, dignity and individuality.
2. Obtain appropriate care/services regardless of race, creed, national origin, sex, age, disability, illness, religious affiliation, economic status or source of payment and in accordance with physician orders.
3. Be advised of policies and procedures regarding the disclosure of clinical records.
4. Confidentiality of all information pertaining to you, your medical care and service.
5. A timely response to your request for service and to expect continuity of services.
6. Select the home medical equipment supplier of your choice.
7. Be fully informed in advance about service to be provided, disciplines that furnish care, frequency of visits and any modifications to the plan of care.
8. Make informed decisions regarding, and participate in, your care planning.
9. Be informed of provider service/care limitations.
10. Be told what service will be provided in your home, how often and by whom and be able to identify visiting staff members through proper identification.
11. Be informed, both verbally and in writing, in advance of services being provided, payment expected from third parties, and an estimate of charges for which you will be responsible.
12. Agree to or refuse any part of the plan of service, care or treatment after the consequences of refusing services/care or treatment are fully presented.
13. Be informed of the grievance procedure and voice grievances of any kind, or recommend changes in policies or staff, without fear of termination of service or other reprisals.
14. Have grievances/complaints regarding care furnished, care not furnished or failure to respect person or property fully investigated.
15. Be informed of any financial benefits to our company, when referred to another organization.
16. Have your communication needs met.

You have the responsibility to:
1. Ask questions about any part of the plan of service or plan of care that you do not understand.
2. Protect the equipment from fire, water, theft or other damage while it is in your possession.
3. Use the equipment for the purpose for which it was prescribed, following instructions provided for use, handling care, safety and cleaning.
4. Supply us with needed insurance information necessary to obtain payment for services and assume responsibility for charges not covered. You are responsible for settlement in full of your account.
5. Be at home for scheduled service visits or notify us in advance to make other arrangements.
6. Notify us immediately of:
a. Equipment failure, damage or need of supplies.
b. Any change in your prescription or physician.
c. Any change or loss in insurance coverage.
d. Any change of address or telephone number, whether permanent or temporary.
e. Discontinued equipment or services.
7. Be respectful of the property owned by our company and considerate of our personnel.
8. Contact us if you acquire an infectious disease during the time we provide services.

Fall Risk Prevention – Information from the Center for Disease Control

Each year, thousands of older Americans fall at home. Many of them are seriously injured, and some are disabled. 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.

FLOORS:

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

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

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.

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.

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

STAIRS AND STEPS:

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

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

Are some steps broken or uneven?

[ ] Fix loose or uneven steps.

Are you missing a light over the stairway?

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

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.

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.

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.

KITCHEN:

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).

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.

BATHROOMS:

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.

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

[ ] Install grab bars inside the tub and next to the toilet.

BEDROOMS:

Is the light near the bed hard to reach?

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

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.

Service, Delivery and Warranty

Business Hours
Our hours of operation are 9:00 A.M. to 5:00 P.M Monday through Friday. We offer 24 hour emergency services for equipment related issues.

Delivery
Deliveries are provided on purchases and/or rentals. It is preferable that routine and repeat orders be called in 24 hours in advance.

Rental Equipment
Customers are responsible for routine maintenance and cleaning of rented equipment according to the instructions provided during the initial set-up.

Returns
All returns accepted only upon management approval and with valid sales receipt, within 30 days of sale. Product must be in original package or container with original tags and labels. Returns of Compression Stockings, Orthopedic Products, Bathroom Equipment or Supplies are not permitted.

Purchased Equipment and Warranties
New equipment is subject to the manufacturer’s warranty. Refer to the warranty information provided to you at the time of purchase. All warranties will be honored under applicable state laws. Used equipment purchased from our company has a 90-day warranty on parts and labor.

Service and Repair
Service or repair on equipment purchased from our company that is no longer covered by the manufacturer’s warranty will be subject to current labor charges. The customer will be informed of their responsibilities regarding the ongoing care and service of the equipment and will be provided with maintenance instructions and how to obtain any service required. All service and repair must be scheduled by calling the office during regular business hours.

PRIVACY NOTICE
Our organization is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment, products, and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and privacy practices concerning your health information.

THE FOLLOWING NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THE INFORMATION CAREFULLY.

• Your confidential healthcare information may be disclosed to employees or business associates of the company when needed to provide you with products and/or services, to secure payment for products and/or services provided, and as needed to operate our business. Employees and business associates of the company will only be provided with the minimum necessary information needed to complete their duties.

• Your confidential healthcare information may be released to other healthcare professionals for the purpose of providing you with quality healthcare.

• Your confidential healthcare information may be released to your insurance provider for the purpose of the company receiving payment for providing you with needed healthcare products and services.

• Your confidential healthcare information may be released to a public health organization or federal organization in the event of the need to report a communicable disease or to report a defective device.

• Your confidential healthcare information may be released to public or law enforcement officials in the event of an investigation in which you are a victim of abuse, a crime or domestic violence.

• Your confidential healthcare information may not be released for any other purpose than that which is identified in this notice without requesting a specific authorization from you to release information for a specific purpose.

• You may be contacted by the company to remind you of the need to re-order regular and routine supplies that you currently receive from the company, or to notify you of other health services that may be of interest to you.

• You have the right to restrict the use of your confidential healthcare information. If you object to your confidential information being disclosed as described in this agreement you may request a “Restriction of Information / Consent” form. Upon completion of this form the company will abide by the restrictions you request. However, the company may choose to refuse to provide continuing service to you if the restrictions you request would interfere with the company maintaining normal treatment, payment, or healthcare operations in regard to your account.

• You have the right to receive confidential communication about your health status and the products and services provided to you.

• You have the right to review and photocopy any/all portions of your healthcare information.

• You have the right to make changes to your healthcare information.

• You have the right to know who has accessed your confidential healthcare information and for what purpose.

• You have the right to possess a copy of this Privacy Notice upon request. This copy can be in the form of an electronic transmission or on paper.

• The company is required by law to protect the privacy of its patients. It will keep confidential any and all patient healthcare information and will provide patients with a list of duties or practices that protect confidential healthcare information.

• The company will abide by the terms of this notice. The company reserves the right to make changes to this notice and continue to maintain the confidentiality of all healthcare information. Patients will receive a mailed copy of any changes to this notice within 60 days of making the changes.

• You have the right to complain to the company if you believe your rights to privacy have been violated. If you feel your privacy rights have been violated, please mail your complaint to the company:

ATTN: Rick Gonzales, CEO
Mendo-Lake Home Respiratory Services
811 Bevins St.
Lakeport, CA 95453

All complaints will be investigated.

• For further information about this Privacy Notice, please contact:

Rick Gonzales

Chief Executive Officer

707-263-9888

• This notice is effective as of 05/06/09.

Local Community Resources (National Resources available upon request)

Sutter lakeside Hospital
1-707-262-5000
http://www.sutterlakeside.org/

St. Helena Hospital Clearlake (Redbud)
1-707-994-6486
http://www.redbudcommunityhospital.org/

Howard Memorial Hospital
1-707-459-6801
http://www.howardhospital.com/

St. Helena Hospital (St. Helena)
1-707-963-3611
http://www.sthelenahospital.org/

Hospice of Lake County
1-707-263-6222
http://www.lakecountyhospice.org/

Mendocino County Hospices
Ukiah 1-707-462-3141/6222
Willits (Phoenix Hospice) 1-707-459-1818
http://www.howardhospital.com/H&H.php