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Orthotic Solutions, Inc.

 15 Kevin Avenue

 Plymouth, MA 02360

 Phone: (508) 224-3510

 Fax:  (508) 224-7559

Orthotic Solutions, Inc. is a privately owned company with the objective of providing patients with a comprehensive array of orthotics, diabetic footwear and positioning devices whether at home or in a health care facility.

Patient Bill of Rights

As an individual receiving health care services from Orthotic Solutions, Inc., let it be known and understood that you have the right to:

1.       refuse delivery of any and all equipment.

2.      prompt delivery of and to be fully informed on the use and care of all Orthotic Solutions, Inc.’s

          equipment or supplies.

3.      have Orthotic Solutions, Inc.’s staff and/or have someone present to communicate in a language that is

          understandable to you.

4.      expect that all information will be kept in strictest confidence.

5.      have your confidentiality, privacy, safety, security and property respected at all times.

6.      expect all equipment to be clean and in good repair.

7.      review Orthotic Solutions, Inc.’s Privacy Notice.

8.      have any questions answered promptly, correctly and courteously.

9.     have personal, cultural, and ethnic preferences considered.

10.    to expect a resolution to any problem or complaint.

11.    know that if he/she is found unresponsive, Orthotic Solutions, Inc.’s policy is for staff to call 911 for emergency medical intervention.

12.   express dissatisfaction and suggest changes without coercion, discrimination, reprisal, or unreasonable interruption in service.

Responsibilities of the Patient:

You and the health care organization are partners in your health care plan. To insure the finest care possible, you must understand your role in your health care program. As a patient of our organization, you are responsible to:

1.      give accurate and complete health information concerning your past use of equipment and any change

         in address, doctor, insurance carrier or prescription.

2.     assist in developing and maintaining a safe environment.

3.      follow instruction in care and use of all equipment and request additional information concerning  

         anything you do not fully understand.

4.      make a conscious effort in showing respect and consideration to the organization’s staff.

5.      order supplies or refills on a timely basis to accommodate reasonable delivery.

6.      have someone at home when delivery is scheduled.

7.       meet financial commitments that have been agreed to with the organization.

8.      accept the consequences of any refusal or choice of noncompliance, including changes in reimbursement

        Eligibility.

Customer concerns are an important form of feed-back for our company.  Any questions or concerns regarding your service or equipment should be directed to the President at Orthotic Solutions, Inc. so that we can improve our service.  It is the president's responsibility to review all formal complaints.  You are entitled to a written response to your formal complaint.

Privacy Notice Effective April 14, 2003

Notice of Privacy Practices

This notice describes how protected health information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.

Orthotic Solutions, Inc.

 15 Kevin Avenue

 Plymouth, MA 02360

 Phone: (508) 224-3510

 Fax:  (508) 224-7559

Our company is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the services we provide to you.  This Notice tells you about the ways in which Orthotic Solutions, Inc. (referred to as “we”) may collect, use, and disclose your protected health information and your rights concerning your protected health information.  “Protected health information” is information about you that can reasonably be used to serve you and that relates to you, or the payment for that care.

We are required by law to maintain the confidentiality of health information that identifies you; as well as by federal and state laws to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information.  We must follow the terms of this Notice while it is in effect.  Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards.

If you have questions about this notice, please contact the Privacy Officer at Orthotic Solutions, Inc. at 508-224-3510 for further information.

The terms of this notice apply to all records containing your health information that are created or retained by our organization.  We reserve the right to revise or amend our notice of privacy practices.  Any revision or amendment to this notice will be effective for all of your records our practice has created or maintained in the past, and for any of your records we may create or maintain in the future.  Our organization will post a copy of our current notice in our office in a prominent location, and you may request a copy of our most current notice by calling us.

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION

• We may use and disclose your protected health information for different purposes.  The examples below are provided to illustrate the types of uses and disclosures we may make without your authorization for payment, home care operations, and treatment.

• Payment.  We use and disclose your protected health information in order bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your equipment.   We also may use and disclose your health information to obtain payment from third parties that may be responsible for such costs, such as family members.  Also, we may use your health information to bill you directly or services and items.

• Home Care Operations. We use and disclose your protected health information in order to perform our home care activities, such as providing equipment appropriate to your needs, or administrative activities, including data management or quality assessment activities.

• Treatment.  We may use and disclose your protected health information to coordinate services with other health care providers involved in your care.  For example, we may obtain and disclose information on CPT diagnosis codes, diagnosis and prognosis, functional limitations, pre-existing health conditions, hospitalizations, prior use of equipment, and information specific to qualifying the patient as dictated by CMN / detailed written order forms.

• Appointment Reminders. We may use and disclose your health information to contact you and remind you of visits / deliveries.

• Health-related Benefits and Services.  We may use and disclose your health information to inform you of health-related benefits or services that may be of interest to you.

• Release of information to Family / friends.  We may release your health information to a friend or family member that is helping you to pay for your health care, or who assists in taking care of you.

• Disclosures Required by Law. We will use and disclose your health information when we are required to do so by federal, state or local law.

OTHER PERMITTED OR REQUIRED DISCLOSURES

• As Required by Law. We must disclose protected health information about you when required to do so by law.

• Public Health Activities.  We may disclose protected health information to public health agencies for reasons such as preventing or controlling disease, injury, or disability.

• Victims of Abuse. Neglect or Domestic Violence.  We may disclose protected health information to government agencies about abuse, neglect, or domestic violence.

• Health Oversight Activities. We may disclose protected health information to government oversight agencies.  Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

• Judicial and Administrative Proceedings. We may disclose protected health information in response to a court or administrative order.  We may also disclose protected health information about you in certain cases in response to a subpoena, discovery request, or other lawful process.

• Law Enforcement.  We may disclose protected health information under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime.

• To Avert a Serious Threat to Health or Safety.  We may disclose protected health information about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

• Special Government Functions. We may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities.

• Workers Compensation.  We may disclose protected health information to the extent necessary to comply with state law for workers’ compensation programs. 

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

• You have certain rights regarding protected health information that the Plan maintains about you.

• Right To Access Your Protected Health Information. You have the right to review or obtain copies of your protected health information records, with some limited exceptions. Usually the records include referral information, delivery forms, billing, claims payment, and medical management records. Your request to review and/or obtain a copy of your protected health information records must be made in writing. We may charge a fee for the costs of producing, copying, and mailing your requested information, but we will tell you the cost in advance.

• Right To Amend Your Protected Health Information. If you feel that protected health information maintained by us is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request if, for example, you ask us to amend information that was not created by us, or you ask to amend a record that is already accurate and complete.  If we deny your request to amend, we will notify you in writing. You then have the right to submit to us a written statement of disagreement with our decision and we have the right to rebut that statement.

• Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures we have made of your protected health information. The list will not include our disclosures related to your treatment, our payment or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security purposes.   Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first accounting that you request within a 12-month period will be free. For additional lists within the same time period, we may charge for providing the accounting, but we will tell you the cost in advance.

• Right To Request Restrictions on the Use and Disclosure of Your Protected Health Information. You have the right to request that we restrict or limit how we use or disclose your protected health information for services, payment, or health care operations. We may not agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency. Your request for a restriction must be made in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit how we use or disclose your information, or both; and (3) to whom you want the restrictions to apply.

• Right To Receive Confidential Communications. You have the right to request that we use a certain method to communicate with you or that we send information to a certain location. For example, you may ask that we contact you at work rather than at home.  Your request to receive confidential communications must be made in writing... We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

• Right to a Paper Copy of This Notice. You have a right at any time to request a paper copy of this Notice.  You may ask us to give you a copy of this notice at any time.

• Contact Information for Exercising Your Rights. You may exercise any of the rights described above by contacting our Privacy Office.

• Complaints. If you believe that your privacy rights have been violated, you may file a complaint with us and/or with the Secretary of the Department of Health and Human Services.  All complaints must be submitted in writing.  You will not be penalized for filing a complaint.

HCFA MEDICARE DMEPOS SUPPLIER STANDARDS

• The supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.

• The 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.

• An authorized individual (one whose signature is binding) must sign the application for billing privileges.

• The supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order The 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.

• The 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.

• The 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.

• The supplier must maintain a physical facility on an appropriate site.

• The supplier must permit HCFA, 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.

• The 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.

• The 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.

• The 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.

• The supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.

• The supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.

• The 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.

• The 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.

• The supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.

• The supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.

• The supplier must not convey or reassign The supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.

• The 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.

• 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.

• The supplier must agree to furnish HCFA any information required by the Medicare statute and implementing regulations.