Assignment of Benefits, Participant Notice,
ASSIGNMENT OF BENEFITS
Thank you for doing business with Edwards Health Care Services (EHCS)! In order to accurately and promptly bill your insurance, please review this information carefully and acknowledge that you read and understand the information contained.
Please save the following documents for your reference:
• Medicare Standards: English | Spanish
• EHCS Patient Bill of Rights
• EHCS Customer Satisfaction, Return Policy & Reorder Process
• EHCS Privacy Practices
It is a requirement from your insurance that we have consent on file, authorizing EHCS to bill your insurance on your behalf. If you do not complete this form, we cannot bill your insurance and you will be responsible for payment for your recent order.
Verification of benefits is not a guarantee of payment. There is no way to determine if a claim will be applied to your deductible or co-pay until after the claim is processed.
I hereby authorize my other third-party insurance providers to pay my medical equipment, supplies and pharmacy benefit directly to EHCS for products furnished to me by EHCS. I further authorize any holder of personal health information (PHI) about me to release such information if required for EHCS to file and process claims on my behalf. I authorize EHCS to release to the Center for Medicare & Medicaid Services (CMS), third party payer and/or its agents any information needed to determine Medicare benefits or for audit purposes.
I have received a copy of EHCS Statement of Privacy Practices as applicable to the Health Insurance Portability and Accountability Act (HIPAA) as well as a copy of CMS’ Supplier Standards and a copy of the Client/Patient Bill of Rights and Responsibilities. I understand how to use the products that have been dispensed to me or will receive training upon receipt, and warranty information is included with those products that carry a warranty.
I understand that I am responsible to pay EHCS for any supplies or services not paid in full by my insurance. If my insurance should pay benefits or process claims directly to me for any merchandise provided by EHCS, I will either endorse all checks as ‘Pay to the order of Edwards Health Care Services, Inc.’ or pay EHCS by personal check or credit card. I will notify EHCS of any changes in my insurance benefits, coverage, carrier or physician. I authorize EHCS to contact me by telephone, auto call, mail, e-mail, text or other means in order to obtain authorization for shipments; or inform me of product recalls, releases and/or introductions; and/or to answer any billing, product or prescription questions.
PARTICIPANT NOTICE & CONSENT
This Participant Notice and Consent authorizes GemCare Wellness, and any sub-contracted vendors, and/or other partners engaged by my Employer’s health plan to conduct services in connection with my Employer’s wellness program (the “Program”).
By executing this Participant Notice and Consent, I am voluntarily authorizing the use and disclosure of health and personal information for purposes of my participation in the Program. I have carefully read this Participant Notice and Consent to understand my rights.
- I hereby authorize GemCare Wellness health coach’s access to any health information that will allow them to create a “Care Plan” for the purposes of providing me direction and information to improve my health status. Their sole purpose for accessing this information is to provide me health information and health outreach.
- I understand that my health information, including my “Care Plan” will not be shared with my employer.
- I understand that my participation in this program may be used to determine my available rewards.
- In the event of a termination of the services provided by GemCare Wellness under the Program, I authorize that GemCare Wellness may send the data and information collected or created to another wellness administrator or health plan to maintain the continuity of information for my participation in the Program.
- I have read and understand the following statements about my rights:
- I may revoke this authorization at any time by notifying GemCare Wellness, in writing, but revocation will not have any effect on any actions that the GemCare Wellness took before receiving the revocation.
- I may receive a copy of the information described on this form upon request.
- The information that is used or disclosed pursuant to this authorization may be re-disclosed by the receiving entity as described above.
- I understand that any participation in this Program is voluntary and that enrollment in or eligibility for health plan benefits is not conditioned upon providing this authorization. By participating in the Program and screening events, I hereby accept all risk to my health that may result from such participation except in the case of gross negligence and I hereby release and agree to hold harmless my employer, my employer’s insurance agent, my employer’s selected vendors, GemCare Wellness, its affiliates, and their respective officers, directors, employees, agents, successors and assigns from any and all liability to myself, my personal representatives, estate, heirs, next of kin and assigns, from any and all claims and causes of actions for all illness or injury to my person resulting from my participation in the Program.
- Consultation with Physician: This Program is not a diagnostic tool; it does not provide, nor is it a substitute for, professional medical advice, diagnosis or treatment. The Program recommends consultation with your healthcare professional for such services. The information provided by the Program is for educational purposes only and should not be interpreted as a diagnosis or as a recommendation for a specific treatment plan, product, or course of action.
- Terms of Agreement: I acknowledge and will comply with all scheduled appointments with my assigned Health Coach/Registered Dietitian. I understand that I may be subject to a $50 penalty fee if there is a failure to attend three consecutive scheduled appointments.
- This Agreement shall be governed by and construed according to the laws of the State of Ohio, without giving effect to conflict of law principles. Any provision of this Agreement found to be invalid by a court having competent jurisdiction shall not affect the validity of the remaining provisions of this Agreement. No waiver of any term or condition of this Agreement shall be deemed a continuing waiver of such term or condition or any other term or condition.
I have carefully read this agreement and understand the terms and conditions of my voluntary participation in the Program. I have read the GemCare Wellness Participant Notice and Consent as of the date signed below or electronically recorded by the online registration system.
NOTICE OF PRIVACY PRACTICES
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.
GEM EDWARDS PHARMACY is a health care product provider subject to the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”). We have always been committed to protecting the information you share with us and are required by law to:
Maintain the privacy of your protected health information; electronic/computer information, telephone & cell phone communications, verbal or faxed information. Provide this Notice of our legal duties and privacy practices with respect to protected health information to any customer who requests it; Abide by the terms of this Notice until adoption of a new one; and To post this notice on our website: www.gemedwardspharmacy.com.
“We” and “us” in this document refers to any individual employed by GEM EDWARDS PHARMACY. All employees are authorized to release your protected health information for the reasons listed below.
Uses and Disclosures for Payment, Treatment or Healthcare Operations: Under HIPAA, we may use, receive or disclose your protected health information for payment, treatment or healthcare operations without obtaining a written authorization from you. Examples of this use include but are not limited to:
Payment: We may use and disclose your protected health information to receive payment for the products and services we provide. Payment activities may include sending claims to your health insurance carrier or medical plan, reviewing the medical necessity of the services rendered with your physician, and coordinating the payment of benefits between medical plans.
Treatment: We may disclose protected health information to your medical care providers for management or coordination of that care.
Healthcare Operations: We may use and disclose your protected health information for our business planning and operational purposes. For example, we may use or disclose your protected health information for activities such as verification of eligibility for benefits with your health insurance carrier or for training and quality control purposes within our organization. Your protected health information is stored in locked file cabinets.
Business Associates: We may contract with other businesses for certain services. These businesses may require access to your personal health information in order to perform a payment or healthcare operations for us. These Business Associates must agree in writing that they will follow these privacy practices and will protect the privacy of your health information.
Unless you authorize us otherwise, your protected health information will be available only to the individuals who need the information to conduct payment, treatment or healthcare operations activities.
Other Uses and Disclosures: Other disclosures GEM EDWARDS PHARMACY may make:
To comply with legal proceedings, court or administrative order or subpoena;
To law enforcement officials for limited law enforcement purposes;
To public Health Authorities for certain required public health activities;
To avert a serious threat to the health or safety of you or any other person;
To comply with laws and regulations related to workers’ compensation or similar programs;
To a coroner, medical examiner or funeral director for purposes of carrying out his or her duties;
To federal officials for lawful intelligence activities or if you are imprisoned;
To your personal representative appointed by you or designated by law;
When otherwise required by law; and
To inform you of other products and services that may be of interest to you.
These uses and disclosures may be subject to special rules under HIPAA or other laws.
Limitations on Use and Disclosure: If a use or disclosure of your protected health information identified in this Notice is subject to a law more stringent than HIPAA, the more stringent law will apply. If you have a question about your rights under any particular federal or state law, please write to the GEM EDWARDS PHARMACY Privacy Contact.
Authorizations Required for all Other Uses and Disclosures: Any other use or disclosure of your protected health information not identified within this Notice will be made only with your written authorization. You have the right to limit the type of information and the persons to whom it should be disclosed. You may revoke your written authorization at any time, and the revocation will be followed to the extent action on the authorization has not yet been taken.
GEM EDWARDS PHARMACY
PO Box 1162
Hudson, OH 44236
Attention: Privacy Contact
Below are your privacy and confidentiality rights as a customer of GEM EDWARDS PHARMACY. Please note that all requests must be made in writing.
You may request that GEM EDWARDS PHARMACY places a restriction on certain uses and disclosures of your protected health information. We are not required to agree to a requested restriction. To request a restriction, please write to our Privacy Contact and provide specific information as to the disclosures that you wish to restrict and the reasons for your request. We will respond in writing.
You may request that our confidential communications of your protected health information be sent to alternative locations or by alternative communicative means. For example, you may ask that we send information or products to your office rather than your home address. We are not required to accommodate your request unless the request is reasonable.
You may make a written request to inspect and obtain a copy of the protected health information that may be used by GEM EDWARDS PHARMACY to make decisions about your care or treatment. Be specific as to the information requested. A reasonable fee may be imposed for copying and mailing the requested information.
You may request that GEM EDWARDS PHARMACY amend your protected health information or record if you believe that information is incorrect or incomplete. GEM EDWARDS PHARMACY cannot amend information it did not create and will refer you to the provider of service if you are requesting amendment to diagnosis or treatment information.
You may receive an accounting of certain disclosures of your protected health information made by GEM EDWARDS PHARMACY for purposes other than treatment, payment or healthcare operations in the six years prior to the date of the request.
Request and obtain a paper copy of this Notice at any time, even if you have agreed to receive it electronically.
To exercise any of these rights, please write to the address listed at the end of this Notice. There are circumstances where GEM EDWARDS PHARMACY is allowed to deny or limit your request. In such event you may have the right to object and obtain a review of our decision. We will provide you with further information about those rights at that time. If you would like more specific information about these matters, contact the GEM EDWARDS PHARMACY Privacy Contact.
Changes to this Notice: GEM EDWARDS PHARMACY reserves the right to change the terms of this Notice and its privacy practices and to make the new provisions effective for all protected health information it maintains. Any amended Notice will be made available to you in the same way that this Notice is available to you.
Complaints and Privacy Contact: You may file a complaint with our Privacy Contact and with the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated. Their addresses are available under contact information below. All complaints must be filed in writing. Federal law prohibits retaliation against you for filing a complaint.
Privacy Contact Information: If you have any questions about this Notice write to:
GEM EDWARDS PHARMACY
PO Box 1162
Hudson, OH 44236
Attention: Privacy Contact
To contact the Secretary of Health and Human Services, write to:
U.S. Department of Health and Human Services
Hubert Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201
Effective Date of Notice: November 6, 2012. GEM EDWARDS PHARMACY is required to follow the terms of this notice until it is replaced. GEM EDWARDS PHARMACY reserves the right to change this Privacy Statement at any time as allowed by law and will notify you of any changes as required by law. GEM EDWARDS PHARMACY reserves the right to make the changes apply to all information GEM EDWARDS PHARMACY maintains.
If you provide us with Personal Information, we may use that information to contact you by e-mail, regular mail, telephone or other means, to provide you with information you requested about specific products or services, provide additional future information about products or services that may be of interest to you, and to learn about and develop products and services concerning a particular disease or condition (e.g. market research). Other or additional information about use of your Personal Information may appear at the point where you are asked to provide Personal Information in a form or data field.