Authorization/Consent for Care/Service: I have been informed of the home care options available to me and of the selection of providers from which I may choose. I authorize Delta Pharmacy and Medical Supply under the direction of the prescribing physician, to provide home medical equipment, supplies and services as prescribed by my physician.

Authorization of Benefits/Authorization for Payment: I hereby assign all benefits and payments to be made directly to Delta Pharmacy & Medical Supply, Inc for any home medical equipment, supplies, and services furnished to me in conjunction with my home care. I authorize Delta Pharmacy & Medical Supply to seek such benefits and payments on my behalf. It is understood that, as a courtesy, Delta Pharmacy & Medical Supply will bill Medicare/Medicaid or other federally funded sources and other payers and insurers providing coverage, with a copy to Delta Pharmacy & Medical Supply. I understand that I am responsible for providing all necessary information and for making sure all certification and enrollment requirements are fulfilled. Any changes in the policy must be reported to Delta Pharmacy & Medical Supply within 30 days of the event. I have been informed by Delta Pharmacy & Medical Supply of the medical necessity for the services prescribed by my physician. I understand that in the event services are deemed not reasonable and necessary, payment may be denied and that I will be fully responsible for payment.

Release of Information: I hereby request and authorize Delta Pharmacy & Medical Supply, the prescribing physician, hospital, and any other holder of information relevant to service, to release information upon request to Delta Pharmacy & Medical Supply, any payer source, physician, or any Other medical personnel or agency involved with service. I also authorize Delta Pharmacy & Medical Supply to review medical history and payer information for providing home health care.
Financial Responsibility: I understand and agree that I am responsible for the payment of all sums that may become due for the services provided. These sums include, but are not limited to, all deductibles, co-payments, out-of-pocket requirements, and non-covered services. If for any reason and to any extent, Delta Pharmacy & Medical Supply does not receive payment from my payer source, I hereby agree to pay Delta Pharmacy & Medical Supply for the balance in full, within 30 days of receipt of invoice. All charges not paid within 45 days of billing date shall be assessed late charges. I am liable for all charges, including collection costs and all attorney costs. I am responsible for all charges regardless of my payer unless my agreement with my health plan holds me harmless.

Returned Goods: I understand that, due to Federal and State Pharmacy Regulations, ancillary items prescribed for home health care cannot be re-dispensed. Therefore, ancillary items cannot be returned for credit. Home Medical Equipment that is rented will be returned after the physician has discontinued service. Sale items cannot be returned. Delta Pharmacy & Medical Supply must be notified within 24 hours of the set-up if any equipment is defective. In the case of defective equipment, an exchange will be made for the defective item.

Client/Patient Handouts: I acknowledge that I have received a copy of the Client/Patient Handouts which contains Client/Patient Rights and Responsibilities, Supplier Standards, Home Safety information, HIPAA Privacy Standards, Emergency Planning, and Advance Directive Information. I acknowledge that the information in the Client/Patient Handouts has been explained to me and that I understand the information. I understand my right to formulate and to issue Advance Directives to be followed should I become incapacitated. I will furnish Delta Pharmacy & Medical Supply with a copy of such document.

Grievance Reporting: I acknowledge that I have been informed of the procedure to report a grievance should I become dissatisfied with any portion of my home care experience. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call 843-761-5255 and speak to Customer Service Supervisor. If your complaint is not resolved to your satisfaction within 5 working days, you may initiate a formal grievance, in writing and forward it to the Governing Body. You can expect a written response within 7 working days or receipt.

Home Health Hotline: You may also make inquiries or complaints about this company by calling your local Social Services Department and/or ACHC.