Patient Intake Form


    Trust Home Medical, LLC (“THM”) is required by the privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) to maintain the privacy of Protected Health Information and to provide its patients with notice of its legal duties and privacy practices concerning Protected Health Information. THM is required to abide by the terms of this Notice so long as it remains in effect. THM reserves the right to change the terms of this Notice of Privacy Practices as necessary and to make the new Notice effective for all Protected Health Information maintained by it. If THM makes material changes to its privacy practices, copies of revised notices will be provided to all patients with their next order. Copies of THM’s current Notice may be obtained by contacting THM at the telephone number or address below.



    Protected Health Information (“PHI”) means individually identifiable health information, as defined by HIPAA, that is created or received by THM and that relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and that identifies the individual or for which there is a reasonable basis to believe the information can be used to identify the individual. PHI includes information of persons living or deceased.



    The following categories describe different ways that we use and disclose PHI. For each category of uses and disclosures we will explain what we mean and, where appropriate, provide examples for illustrative purposes. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted or required to use and disclose PHI will fall within one of the categories.


    Your Authorization – Except as outlined below, we will not use or disclose your PHI unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing except to the extent that THM has taken action in reliance upon the authorization.


    Uses and Disclosures for Payment – THM may make requests, uses, and disclosures of your PHI as necessary for payment purposes. For example, THM may use information regarding your medical condition to process and issue claims for payment from your insurance carrier.


    Uses and Disclosures for Healthcare Operations – THM may use and disclose your PHI as necessary for its healthcare operations. Examples of healthcare operations include activities relating to verifying patients’ insurance coverage, obtaining a physician’s order authorizing the dispensation of medical supplies, processing and shipping orders for medical supplies, regulatory compliance, auditing, business management, quality improvement and assurance, and other functions related to the dispensing of medical supplies to patients.


    Family and Friends Involved in Your Care – If you are available and do not object, we may disclose your PHI to your family, friends, and others who are involved in your care. If you are unavailable or incapacitated and we determine that a limited disclosure is in your best interest, we may share limited PHI with such individuals. For example, THM personnel may use professional judgment to disclose PHI to your spouse concerning orders of medical supplies.


    Business Associates – At times we use outside persons or organizations to help us provide you with the medical supplies you order. Examples of these outside persons and organizations might include vendors that warehouse and ship the medical supplies you order. At times it may be necessary for us to provide certain of your PHI to one or more of these outside persons or organizations.


    Other Products and Services – We may contact you to provide information about other health-related products and services that may be of interest to you. For example, we may use and disclose your PHI for the purpose of communicating with you about new medical supplies that could enhance or substitute for your existing medical supplies.


    Other Uses and Disclosures – We may make certain other uses and disclosures of your PHI without your authorization. 

    • We may use or disclose your PHI for any purpose required by law. For example, we may be required by law to use or disclose your PHI to respond to a court order.

    • We may disclose your PHI for public health activities, such as reporting of disease, injury, birth and death, and for public health investigations

    • We may disclose your PHI to the proper authorities if we suspect child abuse or neglect; we may also disclose your PHI if we believe you to be a victim of abuse, neglect, or domestic violence.

    • We may disclose your PHI if authorized by law to a government oversight agency (e.g., a state insurance department) conducting audits, investigations, or civil or criminal proceedings).

    • We may disclose your PHI in the course of a judicial or administrative proceeding (e.g., to respond to a subpoena or discovery request).

    • We may disclose your PHI to the proper authorities for law enforcement purposes.

    • We may disclose your PHI to coroners, medical examiners, and/or funeral directors consistent with law.

    • We may use or disclose your PHI for research purposes, but only as permitted by law.

    • We may use or disclose PHI to avert a serious threat to health or safety.

    • We may use or disclose your PHI if you are a member of the military as required by armed forces services, and we may also disclose your PHI for other specialized government functions such as national security or intelligence activities.

    • We may disclose your PHI to workers' compensation agencies for your workers' compensation benefit determination.

    • We will, if required by law, release your PHI to the Secretary of the Department of Health and Human Services for enforcement of HIPAA.


    In the event applicable law, other than HIPAA, prohibits or materially limits our uses and disclosures of Protected Health Information, as described above, we will restrict our uses or disclosure of your Protected Health Information in accordance with the more stringent standard.



    Access to Your PHI – You have the right of access to copy and/or inspect your PHI that we maintain in designated record sets. Certain requests for access to your PHI must be in writing, must state that you want access to your PHI and must be signed by you or your representative (e.g., requests for medical records provided to us directly from your healthcare provider). Access request forms are available from us at the address below. We may charge you a fee for copying and postage.

    Amendments to Your PHI – You have the right to request the PHI that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. To be considered, your amendment request must be in writing, must be signed by you or your representative, and must state the reasons for the amendment/correction request. Amendment request forms are available from us at the address below.

     Accounting for Disclosures of Your PHI – You have the right to receive an accounting of certain disclosures made by us of your PHI. Examples of disclosures that we are required to account for include those to state insurance departments, pursuant to valid legal process, or for law enforcement purposes. To be considered, your accounting requests must be in writing and signed by you or your representative. Accounting request forms are available from us at the address below. The first accounting in any 12-month period is free; however, we may charge you a fee for each subsequent accounting you request within the same 12-month period.

    Restrictions on Use and Disclosure of Your PHI – You have the right to request restrictions on certain of our uses and disclosures of your PHI for insurance payment or health care operations, disclosures made to persons involved in your care, and disclosures for disaster relief purposes. For example, you may request that we not disclose your PHI to your spouse. Your request must describe in detail the restriction you are requesting. We are not required to agree to your request but will attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction. You may make a request for a restriction (or termination of an existing restriction) by contacting us at the telephone number or address below.

    Request for Confidential Communications – You have the right to request that communications regarding your PHI be made by alternative means or at alternative locations. For example, you may request that messages not be left on voicemail or sent to a particular address. We are required to accommodate reasonable requests if you inform us that disclosure of all or part of your information could place you in danger. Requests for confidential communications must be in writing, signed by you or your representative, and sent to us at the address below.

     Right to a Copy of the Notice – You have the right to a paper copy of this Notice upon request by contacting us at the telephone number or address below.

    Privacy in treatment – You have the right to privacy for all treatments and medical care.

    Privacy Complaints – If you believe your privacy rights have been violated, you can file a complaint with us in writing at the address below. You may also file a complaint in writing with the Office for Civil Rights of the U.S. Department of Health and Human Services, 200 Independence Ave SW, Washington DC 20201, within 180 days of a violation of your rights. There will be no retaliation for filing a complaint.

    Free from Physical and Mental Abuse – You have the right to feel safe.

    Refute Treatment – If you refuse treatment you will be informed of the consequences of that decision and we will document this in your medical records.

    To refute experimental treatment and drugs – You must have specific written consent for any experimental treatment.

    Right to self-determination – You have the right to make personal choices about life-sustaining treatment, including resuscitative services by advanced directive.


    If you have questions or need further assistance regarding this Notice, you may contact Trust Home Medical’s Privacy Officer by writing to: Trust Home Medical, LLC, Attn: Privacy Officer, 4415 US Hwy 92 W, Plant City, FL 33563-8216; Telephone: (800) 976-3826.


    The products and/or services provided to you by supplier legal business name or DBA 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). The full text of these standards can be obtained from the U.S. Government Printing Office website. Upon request we will furnish you a written copy of the standards.


    Your satisfaction with the medical supplies sold by Trust Home Medical is guaranteed. If you are dissatisfied, for any reason, simply call our toll free number (800) 976-3826 and ask for the Resolutions Team. A specially trained customer service representative will assist you with a return or exchange of your medical supplies. In addition, Trust Home Medical will pay for the shipping cost for your returned medical supplies and the shipping cost for any replacement supplies.


    For warranty information, please contact the supply manufacturer directly using the contact information contained on the supply packaging.


    Medicare (and many private insurance plans) will pay only 80% of the charges after deductibles are met for a patient’s medical supplies. The patient is responsible for all deductibles, co-insurance, and co-payments. Medicare regulations require that Trust Home Medical invoice each patient for any charges which are the patient’s responsibility. If you have any questions about your financial responsibility, please call our toll free number (800) 976-3826 and ask to speak to the Billing Team.


    • To report abuse, neglect, or exploitation, please call toll-free 1-800-962-2873.

    • To report suspected Medicaid fraud, please call toll-free 1-866-966-7226. Medicaid fraud means an intentional deception or misrepresentation made by a health care provider with the knowledge that the deception could result in some unauthorized benefit to him or herself or some other person. It includes any act that constitutes fraud under federal or state law related to Medicaid. To report suspected Medicaid Fraud, please call the Attorney General toll free at 1-866-966-7226. Find out if you are eligible for a reward. Callers may request to remain anonymous.

    • AHCA's toll free number for complaints 1-888-419-3456.


    • When performing self-catheterization or using other medical supplies, always thoroughly wash your hands with soap and water and then dry completely before and after the procedure. Discard any used or non-sterile supplies. Use care when opening the packaging of sterile medical supplies so that they do not become contaminated prior to use.

    • For non-disposable medical supplies, please read manufacturer’s instructions included with your product prior to use.

    • Keep your physician’s telephone number and other emergency contact information handy so that in an emergency, you can find it quickly.

    • Make sure you always have a clear and unobstructed pathway to an exit from your home. If your home has a second floor, keep an emergency fire ladder handy so you can escape a fire safely through a window. If you live in an apartment building or other multi-tenant facility, make yourself aware of the fire exits and escape routes.

    • Test your home smoke detectors every month to make sure the batteries are fresh.

    • Keep a flashlight handy at all times.

    • To be fully informed in advance about care and treatment to be provided by Trust Home Medical.

    • To voice grievances without fear of discrimination or reprisal.

    • Have one’s property treated with respect.


    Trust Home Medical, LLC

    4415 US Hwy 92 W

    Plant City, FL 33563-8216

    Telephone: (800) 976-3826

    Facsimile: (800) 976-3826


    E-mail: [email protected]


    Trust Home Medical’s office is open from 9:00 a.m. to 3:00 p.m. eastern time (U.S.), Monday through Friday. You may call our toll free number after normal business hours and leave a message, which will be returned on the next business day. If you need emergency assistance, please call 911 and contact your physician.


    By signing below, I hereby acknowledge receiving a copy and understanding of the foregoing information, including patient rights and responsibilities, Medicare supplier standards, authorization of benefits and I have received written instructions for the medical supplies I ordered and received.

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