Biocorrect LLC Patient Intake Form

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Financial Responsibility
I understand that orthotics may not be a covered benefit under my insurance plan.
I understand that if insurance has been billed in the last 1-3 years for Custom Orthotics that this may not be a covered benefit under my insurance plan and there may be an out of pocket cost associated. 









































Financial Policy
Every effort is made to ensure that your visit to Biocorrect LLC, is a pleasant experience. It is our practice and obligation to inform patients and your right to know about payment requirements. 
 
Biocorrect LLC, will bill your your claim to your insurance company for possible insurance reimbursement with insurance companies that we participate with. We will also courtesy bill insurance providers that we are out of network with for possible reimbursement. Courtesy billing means that you are responsible for payment at the time of service and you remain fully responsible for your account balance. 
 
Our policy is to collect complete payment at the time services are rendered, unless other payment arrangements have been discussed and made prior to your visit with us. Payment can be made by cash, check, MasterCard, Visa, Discover, AMEX or Care Credit.  
 
We thank you for the opportunity to serve you. If you have any questions regarding our financial policy, please speak with one of our staff members.

Warranty Information
I understand that my orthotics are a custom product and refunds are not available. I also understand that my follow up appointments are part of my treatment plan for one year from the date that I receive my orthotics.

Consent for Care/ Service
I hereby consent and authorize BioCorrect, LLC, its agents, and associates to provide equipment and services to me. I have also been informed of BioCorrect’s financial and warranty policy and will be provided with a copy upon request.  

Release of Information
I hereby acknowledge receipt of the Notice of Privacy Practices from the Organization and was given an opportunity to ask questions and voice concerns.  I hereby consent to and authorize the organization to disclose and release information contained in my clinical record to the health care providers involved in my care, third party payers, utilization review and professional standards review organizations, regulatory review entities and other organizations, companies, community resources, etc. that may/will disclose protected health information about me to carry out treatment, payment, or health care operations.

Authorization for Payment
I certify that all information given by me to the organization in applying for payment under Title XVIII of the Social Security Act is correct.  I consent to the release of all records required to act on this request.  I request that payment of authorized benefits from Medicare be made on my behalf to BioCorrect, LLC.  I have been informed that 100% will be expected for services not covered by Medicare. I will be notified in advance of any products that will not likely be covered, and I agree to notify the Organization of any changes in my insurance plan. 

Client Grievance Procedure
Your complaints or problems are important to BioCorrect, LLC.  We will give full consideration to any problem or complaint and will make an effort to resolve the issue in an agreeable manner.  We assure you, that you will have the opportunity to voice grievances and recommend changes in services and/or policies without discrimination, coercion, unreasonable interruption of services or reprisal in any manner from the Organization.  If you have a complaint, please: 1. Submit the complaint either verbally or in writing to the Administrator, who can be reached at (616) 356-5030. 2. The Administrator will contact you or your representative and will make every effort to resolve the complaint to your satisfaction. 3. If the complaint cannot be resolved to your satisfaction, you may request that the Administrator submit your complaint to the Organization’s Board of Directors.

Receipt of Rights and Responsibilities/ Supplier Standards
I have received a copy and an explanation of the Patient/Client Rights and Responsibilities.  I have also received a copy of the Supplier Standards with which BioCorrect, LLC must comply, in order to participate in the Medicare program.   
 
I understand that if I have any questions regarding any matter, I should contact the Organization during regular business hours, from 8am – 5pm by calling the main phone number:  (616) 356-5030. 

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Notice of Privacy Practices
STATEMENT OF PATIENT RIGHTS
As a patient of BioCorrect, LLC (also referred to as “Organization”), the following rights are afforded to you and your caregiver:
1. The right to be informed in advance upon receiving initial services with BioCorrect, LLC 
 Orally and in writing of your rights and responsibilities.
 The services and equipment to be provided by Organization staff, including the disciplines that will furnish care and the schedule of visits (if applicable).
 Changes in the services or equipment to be provided by Organization staff that may affect your well-being.
 Items and services furnished by (or under arrangements with) Organization for which payment may be made under Medicare.
 Charges for non-covered items or services, furnished by (or under arrangements with) Organization, the amount you may have to pay, and changes in these charges or items and services for which you may be liable.
 Coverage available for items and services under Medicare, Medicaid, and any other Federal program of which Organization is reasonably aware.
2. The right to be treated with dignity courtesy, and respect, and to have property treated with respect.
3. The right to accept or decline service or equipment at any time; and to be informed of the health consequences of this action.
4. The right to make decisions concerning such medical care including the right to accept or refuse medical or surgical treatment and the right to formulate advanced directives (known in Michigan as A Medical Durable Power of Attorney), and to be assured that the BioCorrect, LLC will not condition the provision of care or otherwise discriminate against you based on whether or not you have executed an advance directive.
5. The right to accept or decline participation in research, experimentation, or educational training without punitive action being taken against you.
6. The right to receive an explanation of forms that you are requested to sign.
7. The right, unless judged incompetent, to participate in planning care and treatment, including changes in treatment, services, or equipment.
8. The right to confidentiality of the clinical record and communication between you and Organization personnel regarding your treatment.
 9. The right to receive services and equipment regardless or race, religion, color, national origin, sexual preference, sex, marital status, age, handicap, or diagnosis.
10. The right to be informed of the names, titles, and qualifications of personnel providing your care and equipment.
11. The right to reasonable coordination and continuity of care from referral source to durable medical equipment Organization.
12. The right to privacy during interview, examination and treatment and to refuse observation by those not directly involved in your care.
13. The right to access health records pertaining to you, and the opportunity to question portions of any record and to have the record corrected if appropriate, and the right of transfer information to third-parties from such records in the case of continuing care.
14. The right to voice concerns/complaints regarding the treatment, care, or equipment that is (or fails to be) provided, or regarding the lack of respect for property by anyone who is providing care or equipment on behalf of Organization, without discrimination or reprisal. To voice your concerns or complaints, call the supervisor at the BioCorrect, LLC office.
15. The right to receive an investigation by Organization of complaints made by you, your family, or guardian regarding treatment or care or equipment that is (or fails to be) provided, or regarding the lack to respect for property by anyone who is providing care or equipment on behalf of Organization. We will document both the existence and resolution of the complaint.
PATIENT RESPONSIBILITES
It is your responsibility:
 1. To become independent in care and equipment usage to the extent possible using self, family or other resources.
2. To give Organization staff accurate information so appropriate decisions for services, equipment, and payment can be made.
3. To engage a physician and remain under medical supervision, and to inform Organization staff of changes in your use of equipment or services.
4. To participate with Organization staff in designing and implementing your service plan or selection of equipment.
5. To supply medication, equipment, or supplies that the Organization is unable to provide. 6. To promptly inform Organization staff of changes in your health or reactions to care, equipment, and services.
7. To promptly ask for additional information regarding any aspect of your conditions, care or equipment which you do not understand.
8. To promptly inform Organization staff of any aspects of your care and/or equipment which you do not choose to follow.
9. To assume responsibility for the consequences of your refusal of treatment.
10. To promptly notify BioCorrect, LLC of the existence of an Advance Directive and of changes in your Advance Directive, and to provide us with a copy of the Advance Directive prior to its implementation.
11. To provide the insurance and financial information necessary to determine the sources of payment for your care.
12. To request an adjustment in BioCorrect, LLC charges for which you are responsible and which are beyond your ability to pay.
13. To notify BioCorrect, LLC office promptly in advance of a delivery or visit you must cancel.
14. To respect the rights of the BioCorrect, LLC staff providing service. We rely upon you to meet your responsibilities so that appropriate care may be provided.
 BioCorrect, LLC PROTOCOL FOR RESOLVING COMPLAINTS FOR ALL PATIENTS INCLUDING MEDICARE BENEFICIARIES
The patient has the right to freely voice grievances and recommend changes in care or services without fear of reprisal or unreasonable interruption of services. Service, equipment, and billing complaints will be communicated to management and upper management. These complaints will be documented on the Documentation of Patient Complaints Form and completed forms will include the patient’s name, address, telephone number, and health insurance claim number, a summary of the complaint, the date it was received, the name of the person receiving the complaint, and a summary of actions taken to resolve the complaint. All complaints will be handled in a professional manner. All logged complaints will be investigated, acted upon, and responded to in writing or by telephone by a manager within a reasonable amount of time after the receipt of the complaint. If there is no satisfactory resolution of the complaint, the next level of management will be notified progressively and up to the president or owner of the company. The patient will be informed of this complaint resolution protocol at the time of initial set-up of service. Your complaints or problems are important to BioCorrect, LLC We will give full consideration to a problem or complaint and will make an effort to resolve the issue in an agreeable manner. We assure you, that you will have the opportunity to voice grievances and recommend changes in services and/or policies without discrimination, coercion, unreasonable interruption of services, or reprisal in any manner from the Organization. If you have a complaint, please do the following:
1. Submit the complaint either verbally by phone: (616) 356-5030 during and after business hours or in writing to Administrator: BioCorrect, LLC 5147 E. Paris Ave. SE, Suite 21 Kentwood, MI 49512
2. Management staff will contact you or your representative within five (5) calendar days, and will make every effort to resolve the complaint to your satisfaction.
3. If the complaint cannot be resolved to your satisfaction, you may request that the Administrator submit your complaint to the Organization’s Board of Directors.
4. We will complete our investigation of the complaint and will provide written notification to you within 14 calendar days. ** THANK YOU FOR SHARING YOUR CONCERNS WITH US! ** NOTICE OF PRIVACY PRACTICES FOR BIOCORRECT, LLC THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Our Agency is required by law to maintain the privacy of protected health information and to provide you adequate notice of your rights and our legal duties and privacy practices with respect to the uses and disclosures of protected health information. (45 CFR 164.520) We will use or disclose protected health information in a manner that is consistent with this notice. The agency maintains a record (paper/electronic file) of the information we receive and collect about you and of the care we provide to you. This record includes physician’s orders, assessments, equipment and services provided, clinical progress notes and billing information. As required by law, the agency maintains policies and procedures about our work practices, including how we provide and coordinate care provided to our patients. As our patient, information about you must be used and disclosed to other patients for purposes of treatment, payment and health care operations. Examples of information that must be disclosed:
 Treatment: Providing, coordinating or managing health care and related services, consultation between health care providers relating to a patient or referral of a patient for medical services or equipment from one provider to another.
 Payment: Billing and collecting for services provided, determining plan eligibility and coverage, utilization review (UR), precertification, medical necessity review.
 Health Care Operations: General agency administrative and business functions; quality assurance/improvement activities; medical review; auditing functions; developing clinical guidelines; determining the competence or qualifications of health care professionals; evaluating agency performance; conducting training programs with new employees; survey, certification, accreditation and credentialing activities; internal auditing; and certain marketing activities. The following uses and discloses do not require your consent, and include, but are not limited to, a release of information contained in financial/medical records including information concerning communicable diseases such as HIV, AIDS, drug/alcohol abuse, psychiatric diagnosis and treatment records and/or laboratory test results, medical history, treatment progress, or any other related information to:
 Your insurance company, self-funded or third-party health plan, Medicare, Medicaid or any other person or entity that may be responsible for paying or processing for payment any portion of your bill for services; 
 Any person or entity affiliated with or representing us for purposes of administration, billing, and quality and risk management; 
 Any hospital, nursing home or other health care facility to which you may be admitted; 
 Any assisted living or personal care facility of which you are a resident; 
 Any physician providing care; 
 Licensing and accrediting bodies; 
 Other health care providers to initiate treatment.
We are permitted to use or disclose information about you without consent or authorization in the following circumstances:
 In emergency treatment situations, if we attempt to obtain consent as soon as practicable after treatment;
 Where substantial barriers to communicating with you exist and we determine that the consent is clearly inferred from the circumstances;
 Where we are required by law to provide treatment and we are unable to obtain consent;
 Where the use or disclosure of medical information about you is required by federal, state or local law;
 Certain judicial administrative proceedings;
 Certain law enforcement purposes;
 To coroners, medical examiners, and funeral directors;
 For certain research purposes;
 To avert a serious threat to health and safety;
 For specialized government functions;
 For Worker’s Compensation purposes. We are permitted to use or disclose information about you without consent or authorization provided you are informed in advance and given the opportunity to agree to or prohibit or restrict the disclosure in the following circumstances:
 Use of directory of individuals served by our Agency
 To a family member, relative, friend, or other identified person, the information relevant to such person’s involvement in your care of payment for care; to notify a family member, relative, friend, or other identified person of the individual’s location, general condition or death. Other uses and disclosures will be made only with your written consent. That consent may be revoked, in writing, at any time, except in limited situations. You have the right to:
 Request restrictions on uses and disclosures of your protected health information.
 Confidential communication of protected health information.
 Inspect and obtain copies of protected health information.
 Request to amend protected health information.
 Receive an accounting of disclosures of protected health information.
 Obtain a paper copy of this notice. If you believe that your privacy rights have been violated, you may complain to the Agency or to the Secretary of the U.S. Department of Health and Human Services. There will be no retaliation against you for filing a compliant. For further information regarding filing a complaint, contact: BioCorrect, LLC 5147 E. Paris Ave. SE, Suite 21 Kentwood, MI 49512 ATTN: Privacy Officer The Privacy Officer can be contacted by telephone at (616) 356-5030. IX. Effective Date This Notice is effective October 1, 2011