NOTICE OF PRIVACY PRACTICES

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.

DEFINITIONS

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.

USES & DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATI ON

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).

TRUST HOME MEDICAL, LLC PATIENT INTAKE INFORMATION

  • 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.

YOUR RIGHTS

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 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.

FOR FURTHER INFORMATION

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, PO Box 33, Valrico, FL 33565; Telephone: (800) 976-3826.

MEDICARE DMEPOS SUPPLIER STANDARDS

Below is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c) and went into effect December 11, 2000. In accordance with Medicare regulations, Trust Home Medical, LLC is providing this copy of these standards to you.

  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 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. The supplier location must be accessible to beneficiaries during reasonable business hours and must maintain a visible sign and posted hours of operation.
  8. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards.
  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 (e.g., 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.

SUPPLY RETURNS & COMPLAINTS

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.

FINANCIAL RESPONSIBILITY

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.

HOME SAFETY INFORMATION

  • When performing self-catheterization, 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.
  • 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.

CONTACT INFORMATION

Trust Home Medical, LLC

PO Box 33

Valrico, FL 33565

Telephone: (800) 976-3826

Facsimile: (800) 976-3826

Website: www.TrustHomeMedical.com E-mail: [email protected]

BUSINESS HOURS & AFTER HOURS CALLS

Trust Home Medical’s office is open from 9:00 a.m. to 5:00 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.