Patient Information Packet

Welcome to Freedom In Mobility. We appreciate the opportunity to serve you. Our staff of professional and trained service representatives will be available to take care of your mobility, seating and positioning needs. The following information should prove helpful to familiarize you with Freedom In Mobility. Suggestions to improve services are always appreciated.

Freedom In Mobility was established as a “center of excellence” to provide appropriate Assistive Technology to the physically challenged population. Our goal is to satisfy the needs of patients, caregivers and medical professionals.

Office Hours:  Our offices are open from 9:00 A.M. – 5:00P.M., Monday through Friday. Our office phone numbers are 256-517-4404 (N. Alabama) , 901-366-2220 (W. Tennessee) and   

(865) 351-1369 (E. Tennessee).  In the event of a life-threatening emergency or disaster, you should contact 911 or your physician immediately.

Scope of Services: Freedom In Mobility is a certified Rehab Dealer. Freedom In Mobility employs certified Assistive Technology Practitioners and Suppliers. Freedom In Mobility is a resource center for therapist input when referring therapeutic equipment. Freedom In Mobility provides manual and power chair evaluations, seating assessments and evaluations, as well as alternate positioning aids.

Complaint Resolution: Your concerns or complaints are welcome. If you wish to voice a concern, please call and ask for a Supervisor.

Billing: All billing is done at branch level. Patient copays are collected at the time of delivery.

Freedom In Mobility’s geographic service areas:

North Alabama Branch:

Counties in Alabama include:

Lauderdale, Limestone, Madison, Jackson, Morgan, Marshall, Dekalb, Winston, Cullman, Blount, Jefferson

FIM geographic service area includes patients within the Huntsville Metropolitan Area, and typically within a 2 hour drive time in the rural surrounding areas (Approx. 150 miles). FIM Management may approve exceptions outside of these areas

West Tennessee Branch:

Counties in Tennessee include: Shelby, Fayette, Hardeman, Tipton, Haywood, Madison, Dyer, Lauderdale, Crockett, Chester

Counties in Mississippi include: Desoto, Marshall, Benton, Tippah, Tunica, Tate, Coahoma, Quitman, Panola, Lafayette 

Counties in Arkansas (contiguous) include: Crittenden

FIM geographic service area includes patients within the Huntsville Metropolitan Area, and typically within a 2 hour drive time in the rural surrounding areas (Approx. 150 miles). FIM Management may approve exceptions outside of these areas

East Tennessee Branch:

Counties in Tennessee include: Anderson, Bledsoe, Blount, Bradley, Campbell, Carter, Claiborne, Cocke, Cumberland, Grainger, Greene, Hamblen, Hamilton, Hancock, Hawkins, Jefferson, Johnson, Knox, Loudon, Marion, McMinn, Meigs, Monroe, Morgan, Polk, Rhea, Roane, Scott, Sevier, Sullivan, Unicoi, Union, Washington

FIM geographic service area includes patients within the Huntsville Metropolitan Area, and typically within a 2 hour drive time in the rural surrounding areas (Approx. 150 miles). FIM Management may approve exceptions outside of these areas

PATIENT RIGHTS AND RESPONSIBILITIES

As our customer, you are hereby provided this Bill of Rights. You have the right to be notified in writing of your rights and obligations before treatment has begun. The patient’s family or guardian may exercise the patient’s rights when the patient has been judged incompetent. If client cannot read the statement of rights and responsibilities, it is read and a copy given to the client/patient in a language the client/patient understands.  For a minor or a client needing assistance in understanding these rights and responsibilities, both the client/patient and the parent, legal guardian, or other responsible person are fully informed of these rights and responsibilities.

We fulfill our obligation to protect and promote the rights of our patients, including the following:

Customer Rights

As the patient/caregiver, you have the RIGHT to:

• Be treated with dignity and respect.
• Be fully informed in advance about care/service to be provided, including the disciplines that furnish care and the frequency of visits, as well as any modifications to the plan of      care.
• Be informed, in advance of care/service being provided and their financial responsibility.
• Receive information about the scope of services that the organization will provide and specific limitations on      those services.
• Participate in the development and periodic revision of the plan of care.
• Refuse care or treatment after the consequences of refusing care or treatment are fully presented.
• Refuse experimental treatment and drugs. The patient's written consent for participation in research must be      obtained and retained in the medical record
• Be informed of client/patient rights under state law to formulate an Advanced Directive, if applicable.
• Have one's property and person treated with respect, consideration, and recognition of client/patient dignity and individuality.
• Be able to identify visiting personnel members through proper identification.
• Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source,  and misappropriation of client/patient property. 
• Be fully informed of the agency phone number for information, questions and/or to Voice grievances/complaints regarding treatment or care or lack of respect of property, or recommend changes in policy, personnel, or care/service without restraint, interference, coercion, discrimination, or reprisal.
• Have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated and documented in timely manner.
• Confidentiality and privacy in treatment and personal care and of all information contained in the client/patient record and of Protected Health Information (PHI).
• Be advised on the agency's policies and  procedures regarding the disclosure of clinical records.
• Choose a healthcare provider, including an attending physician*, if applicable.
• Receive appropriate care without discrimination in accordance with physician’s* orders, if applicable.
• Be informed of any financial benefits when referred to an organization.
• Be fully informed of one's responsibilities.

Customer Responsibilities

As the patient/caregiver, you are RESPONSIBLE for;

• Notifying the company of change of address, phone number, or insurance status.
• Notifying the company when service or equipment is no longer needed.
• Notifying the company in a timely manner if extra equipment or services will be needed.
• Participating as in the plan of care/treatment.
• Notifying the company of any change in condition, physician orders, or physician.
• Notifying the company of an incident involving equipment.
• Meeting the financial obligations of your health care as promptly as possible.
• Providing accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters pertinent to your health.
• Your actions if you do not follow the plan of care/treatment.

Our Rights

As your provider of choice we have the right to:

• Terminate services to anyone who knowingly furnishes incorrect information to our company to secure durable medical equipment.
• To  refuse services to anyone who during direct care is threatening, intoxicated by alcohol, drugs and/or chemical substances and could potentially endanger our staff and patients.

Freedom In Mobility provides a process for patients/clients to lodge an oral, written, or telephone complaint about the products and services provided. Freedom In Mobility has a complaint resolution system for identifying, responding to, and resolving complaints in a timely manner.  All written, oral, and telephone complaints are documented with the following information:

• Name address, and contact number of the individual voicing the complaint
• A summary of the complaint, including:

- Date received

- Name of the person receiving the complaint

• A summary of actions taken to resolve the complaint and resolution
• If an investigation is not conducted, the name of the person who made that decision, along with the reason for not conducting an investigation 
• Signature of supervisor

All employees are trained in how to handle complaints. Copies of all complaints and investigations are kept on-file for at least three years. All complaints are summarized and presented to Executive Management annually. 

Within five (5) calendar days of receiving a patient/client complaint, Freedom In Mobility notifies the patient/client, using either oral, telephone, e-mail, fax, or letter format, that it has received the complaint and that it is investigating.  Within 14 calendar days, Freedom In Mobility provides written notification to the beneficiary of the results of its investigation and response. Freedom In Mobility maintains documentation of all complaints that it receives, copies of the investigations, and responses to beneficiaries.

If you have a complaint, please contact us at 256-517-4404 or 901-366-2220 and ask to speak with a supervisor

Additionally, you may contact Centers for Medicare and Medicaid Services (CMS) at 1(800) MEDICARE, if needed. You may also contact our accreditation provider if needed. Our accreditation provider is ACHC and can be reached at (919) 785-1214.

Freedom In Mobility, LLC, has a comprehensive emergency preparedness plan in case a disaster occurs. Disasters may include fire to our facility, chemical spills in the community, hurricanes, tornadoes and community evacuations. Our primary goal is to continue to service your health care needs. It is your responsibility to contact us regarding any supplies you may require when there is a threat of disaster or inclement weather so that you have enough supplies to sustain you. 

If a disaster occurs, follow instructions from the civil authorities in your area. We will utilize every resource available to continue to service you. However, there may be circumstances where we cannot meet your needs due to the scope of the disaster. In that case, you must utilize the resources of your local rescue or medical facility. We will work closely with authorities to ensure your safety.

Here are some helpful guidelines to help you keep a careful eye on your home and maintain safe habits. Correct unsafe conditions before they cause an accident. Take responsibility and keep your home safe. 

Medicines

· If children are in the home, store medications and poisons in childproof containers and out of reach. 

· All medicines should be labeled clearly and left in original containers.

· Do not give or take medicines that were prescribed for other people.

· When taking or giving medicines, read the label and measure doses carefully. Know the side effects of the medicines you are taking.

· Throw away outdate medicines by pouring down a sink or flushing down the toilet.

Mobility items

When using mobility items to get around such as; canes, walkers, wheelchairs, or crutches you should use extra care to prevent slips and falls.

· Use extreme care to avoid using walkers, canes, or crutches on slippery or wet surfaces.

· Always put the wheelchairs or seated walkers in the lock position when standing up or before sitting down.

· Wear shoes when using these items and try to avoid obstacles in your path and soft and uneven surfaces.

Slips and Falls

Slip and falls are the most common and often the most serious accidents in the home. Here are some things you can do to prevent them in your home.

· Arrange furniture to avoid an obstacle course

· Install handrails on all stairs, showers, bathtubs and toilets.

· Keep stairs clear and well lit.

· Place rubber mats or grids in showers and bath tubs.

· Use bath benches or shower chairs if you have muscle weakness, shortness of breath, or dizziness.

· Wipe up all spilled water, oil, or grease immediately.

· Pick-up and keep surprises out from under foot, including electrical cords and throw rugs.

· Keep tubing under your control. Tubing may catch on furniture, doors, knobs, throw rugs, or other items on floor.

· Keep drawers and cabinets closed.

· Install good lighting to avoid groping in the dark.

Lifting

If it is too big, too heavy, or too awkward to move alone – GET HELP. Here are some things you can do to prevent low back pain or injury.

· Stand close to the load with your feet apart for good balance.

· Bend your knees and “straddle” the load.

· Keep your back as straight as possible while you lift and carry the load.

· Avoid twisting your body when carrying a load.

· Plan ahead – clear your way.

Electrical Accidents

Watch for early warning signs – e.g. overheating, a burning smell, sparks. Unplug the appliance and get it checked right away. Here are some things you can do to prevent electrical accidents.

· Keep cords and electrical appliances away from water.

· Do not plug cords under rugs, through doorways or near heaters. Check cords for damage before use.

· Extension cords must have a big enough wire for larger appliances.

· If you have a broken plug, outlet, or wire, get it fixed right away.

· Use a ground on 3-wire plugs to prevent shock in case of electrical “fault.”

· Do not overload outlets with too many plugs.

· Use three-prong adapters when necessary.

Smell Gas?

· Open windows and doors.

· Shut off appliance involved. You may be able to refer to the front of your telephone book for instructions regarding turning off the gas to your home.

· Don’t use matches, light candles or turn on electrical switches.

· Don’t use telephone – dialing may create electrical sparks.

· Call the Gas Company from a neighbor’s home.

· If your gas company offers free annual inspections, take advantage of them.

Fire

Pre-plan and practice your fire escape. Prepare a plan with at least two ways out of your home. If your fire exit is through a window, make sure it opens easily. If you are in an apartment, know where the exit stairs are located. Do not use the elevator in a fire emergency. You may notify the fire department ahead of time if you have a disability or special needs. Here are some steps to prevent fires:

· Install smoke detectors. They are your best early warning. Test frequently and change the battery every year.

· Throw away old newspapers, magazines and boxes.

· Empty wastebaskets and trashcans regularly.

· When there is oxygen in use, place a “No Smoking” sign in plain view of all persons entering the home and do not permit anyone to smoke near the patient

· Do not allow ashtrays or used matches to be tossed into wastebaskets unless you know they are out. Wet down first or dump into toilet.

· Have your chimney and fireplace checked frequently. Look for and repair cracks and loose mortar. Keep paper, wood, and rugs away from area where sparks could hit them.

· Be careful when using space heaters.

· Follow instructions when using heating pad to avoid serious burns.

· Check your furnace and pipes regularly. If nearby walls or ceilings feel hot, add insulation.

· Keep a fire extinguisher in your home and know how to use it.

If you have a fire or suspect fire

1. Take immediate action per plan – escape is your top priority.

2. Get help on the way – with no delay. CALL 9-1-1.

3. If your fire escape is cut-off, close the door and seal the cracks to hold back smoke. Signal help from the window.

Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c). 

1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements and cannot contract with an individual or entity to provide licensed services. 

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. This standard requires that the location is accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records. 

8. A supplier must permit CMS, 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. 

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, answering service or cell phone during posted business hours 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 contacting a Medicare beneficiary based on a physician’s oral order unless an exception applies. 

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; i.e., 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. 

This page remains with the patient 

UPDATED 5/2014

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

Freedom In Mobility, LLC, is committed to preserving the privacy of your personal health information. In fact, we are required by law to protect the privacy of your medical information and to provide you with this notice describing the following how your medical information is used and disclosed for your treatment, to obtain payment for treatment, administrative purposes and to evaluate the quality of care that you receive.

Uses and Disclosures: We use and disclose elements of your Protected Health Information (PHI) in the following ways:

• Treatment: including, but not limited to, inpatient, outpatient or psychiatric care.
• To your treating      physician(s).
• Payment: including, but not limited to, asking you about your health care plan(s), or other      sources of payment; preparing and sending bills or claims; and collecting unpaid amounts, either ourselves or through a collection agency or attorney.

· Health care operations: including, but not limited to, financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

• Disclosures when release is authorized by law: including, but not limited to, judicial      settings and to health oversight regulatory agencies, law enforcement and correctional institutions.
• Uses or disclosures for specialized government functions: including, but not      limited to, the protection of the President or high-ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign services.
• In emergency situations or to avert serious health / safety situations.
• If you are a member of the armed forces, we may release medical information about you      and your dependents as requested by military command authorities.
• Disclosures of de-identified information.
• Disclosures relating to worker’s compensation claims.
• To medical examiners, coroners or funeral directors to aid in identifying you or to help them in performing their duties.
• To organizations that handle organ and tissue donations.
• To public health organizations or federal organizations in the event of a communicable      disease or to report a defective device or untoward event to a biological product (food or medication).
• Disclosures to “business associates” who perform health care operations for us and who      commit to respect the privacy of your health information.
• We may be required or permitted by certain laws to use and disclose your medical information for other purposes without your consent or authorization
• We will notify you by e-mail or US Mail of any breaches of your PHI

You have the following rights concerning your protected health information (PHI):

Restrictions: To request restricted access to all or part of your PHI. To do this, contact the organization’s HIPAA Privacy and Security Officer, Forrest Owens (901)338-5200. We are not required to grant your request and you do not have the right to restrict disclosures required by law. If we do agree, we must honor the restrictions you request.

Confidential Communications: To receive correspondence of confidential information by alternate means or location such as phoning you at work rather than at home or mailing your health information to a different address. To do this, contact the organization’s HIPAA Privacy and Security Officer. We will take reasonable actions to accommodate your request.

Access: To inspect or receive copies of your PHI. To do this, contact the organization’s HIPAA Privacy and Security Officer. In certain circumstances you may not have the right to access your records if the organization reasonably believes (or has reason to believe) that such access would cause harm. Examples include, but are not limited to, certain psychotherapy notes, information compiled in reasonable anticipation of or for use in civil, criminal or administrative actions or proceedings, or information obtained from someone other than a healthcare provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

Amendments / Corrections: To request changes be made to your PHI. To do this, contact the organization’s HIPAA Privacy and Security Officer. We are not required to grant your request if we did not create the record or the record is accurate and complete. If we deny your request for amendment / correction, we will notify you why, how you can attach a statement of disagreement to your records (which we may rebut), and how you can complain. If we agree to the request, we will make the correction within 60 days and will send the corrected information to persons we know who got the wrong information, and others you specify.

Accounting: To receive an accounting of the disclosures by us of your PHI. To do this, contact the organization’s HIPAA Privacy and Security Officer. By law, the list will not include disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law, we can have one 30-day extension of time if we notify you of the extension in writing. We are not required to give you a list of disclosures that occurred before April 14, 2003.

This Notice: To get updates or reissue of this notice, at your request.

Complaints: To complain to us or the U.S. Department of Health & Human Services if you feel your privacy rights have been violated. To register a complaint with us, contact: 

Barbara Stampul, Acting Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services
Sam Nunn Atlanta Federal Center, Suite 16T70
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909
Customer Response Center: (800) 368-1019
Fax: (202) 619-3818
TDD :(800) 537-7697
Email: ocrmail@hhs.gov

The law forbids us from taking retaliatory action against you if you complain.

Our Duties: We are required by law to maintain the privacy of your protected health information (PHI). We must abide by the terms of this notice or any update of this notice.

As a patient of Freedom In Mobility, LLC, you have important rights relating to inspecting and copying your medical information that we maintain, amending or correcting the information, obtaining an accounting of our disclosures of your medical information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated.