Bellevue Healthcare 6/18/2018 - Laserfiche WebLink

RENTAL AGREEMENT- I acknowledge that 1)The equipment listed on the delivery slip is being rented only, and further acknowledge that Bellevue Healthcare owns the equipment. 2) I have received the equipment in good working order. 3) I am responsible for the rented equipment and must pay a replacement fee if it is broken/damaged or lost. 4)A cleaning fee of$25.00 may be charged if equipment is returned "unreasonably"dirty. 5) Rental periods are for one-month periods unless specified otherwise. No refund will be made if the equipment is returned early. 6)All outstanding balances will be turned over to collections if unpaid for 3 months. 7)The rental period is determined by the insurance company. If no insurance is involved, it will rent up to the purchase price for the equipment after which ownership of the equipment will transfer to the patient. 8) It is the responsibility of the patient/representative to return to or contact Bellevue Healthcare when the equipment is no longer needed. 9) Bellevue Healthcare is not responsible for any damage that may occur to the lessee's property caused by equipment during use. CREDIT CARD - Bellevue Healthcare requires a credit card to be kept on file for all rental items and your account will be set up on auto-pay. Your credit card information is kept confidential and secure and will only be used as a convenient method of payment for recurring rentals, or any portion of services that your insurance doesn't cover, or in the case a rental is not returned to Bellevue Healthcare. Your credit card will be processed after the claim has been filed and processed by your insurer when applicable. Patient invoices will be charged on the due date of the invoice, the due date is typically 20 days after the anniversary date. It is your responsibility to contact us if you have questions or concerns on your invoice. RETURN POLICY- 1) Hygienic items are non-returnable and non-refundable (including, but not limited to, all equipment used in the bathroom). 2) Returnable equipment may be returned with this receipt within 10 days of purchase. 3) Equipment must be unused and in original packaging. 4)All returns are subject to a minimum 25% restocking fee. 5)Custom items (items ordered specifically for you)are non-returnable. 6) Items being returned must be returned directly to Bellevue Healthcare or they are subject to a pick-up fee. 7) Used equipment that was purchased was purchased "as-is" and is non-returnable INFORMED CONSENT- What company provides your Medical Insurance: I attest that my insurance benefits were explored and Bellevue Healthcare will not submit a claim for the following reason: UPGRADED EQUIPMENT—This item is deluxe equipment. I attest I was offered the standard equipment and I am electing a deluxe version of a covered item. I am responsible for the charges above the allowed amount by my insurance. INSURANCE TRANSACTIONS - Assignment of Benefits: I request that payment of authorized insurance benefits be made either to me or on my behalf. I assign to Bellevue Healthcare these benefits for any service furnished to me by that supplier. I authorize any holder of medical information about me to release to Bellevue Healthcare, the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I further authorize Bellevue Healthcare to release to my insurance company any and all information pertaining to me for benefit determination. MEDICARE BENEFICIARIES: Certain items classified as "Inexpensive and Routine" can be rented or purchased. Medicare also allows a Purchase Option for applicable Complex Rehab Chairs that fall into the Capped Rental Category. By signing below, I acknowledge receipt of the equipment listed above and have received instructions on proper equipment use. If I am not the end user of the products listed, it is my responsibility to relay the information to them. I understand I can contact Bellevue Healthcare for any issues regarding the equipment. I understand that I am under the care of my physician and that Bellevue Healthcare has not prescribed the equipment, or made any representations regarding efficacy, length of need, its therapeutic value, and is not liable for any injuries or damages resulting from the use of the equipment and will be held harmless. ***Bellevue Healthcare makes no guarantee of payment for any equipment provided. Patient understands that they will be financially responsible for any equipment or services provided that are not covered by their insurance company or any misrepresentation of insurance at the time services are rendered. Patient acknowledges receipt of Bellevue Healthcare privacy policy and supplier standards.*** C Cc,S� e Print Name ' Bene' .• .r Pare y n/Representative)Signature ate Relationship to Beneficiary(if Applicable) Technician Initials A S1 air AP' 'MED A • ., ,M f .II, . City erk JAMES!),IILES,Ci tet'ney 1111111M 1111111111111 III I II IIII III S Cus les omer COrder ity Cultural Department,omer ID 6 1126511858371 Page 2 of 2