PATIENT BILL OF RIGHTS AND RESPONSIBILITIES

To ensure the finest care possible, as a Patient receiving our Pharmacy/DME services, you should understand your role, rights and responsibilities involved in your own plan of care.

 

Patient Rights

  • To select those who provide you with DME and Pharmacy services
  • To receive the appropriate or prescribed services in a professional manner without discrimination relative to your age, sex, race, religion, ethnic origin, sexual preference or physical or mental handicap
  • To be treated with friendliness, courtesy and respect by each and every individual representing our Pharmacy, who provided treatment or services for you and be free from neglect or abuse, be it physical or mental
  • To assist in the development and preparation of your plan of care that is designed to satisfy, as best as possible, your current needs, including management of pain
  • To be provided with adequate information from which you can give your informed consent for commencement of services, the continuation of services, the transfer of services to another health care provider, or the termination of services
  • To request and receive complete and up-to-date information relative to your condition, treatment, alternative treatments, risk of treatment or care plans
  • To receive treatment and services within the scope of your plan of care, promptly and professionally, while being fully informed as to our Pharmacy’s policies, procedures and charges
  • To request and receive data regarding treatment, services, or costs thereof, privately and with confidentially
  • To be given information as it relates to the uses and disclosure of your plan of care
  • To have your plan of care remain private and confidential, except as required and permitted by law

 

Patient Responsibilities

  • To provide accurate and complete information regarding your past and present medical history
  • To agree to a schedule of services and report any cancellation of scheduled appointments and/or treatments
  • To participate in the development and updating of a plan of care
  • To communicate whether you clearly comprehend the course of treatment and plan of care
  • To comply with the plan of care and clinical instructions
  • To accept responsibility for your actions, if refusing treatment or not complying with, the prescribed treatment and services
  • To respect the rights of Pharmacy personnel
  • To notify your Physician and the Pharmacy with any potential side effects and/or complications

 

Assignment of Benefits (Medicare Only)

  • I assign the right and responsibility to the pharmacy to bill on my behalf, and accept payment for Medicare DMEPOS products and services provided to me (The Beneficiary)
  • I understand that I am responsible to pay any deductible amount applied to the claims and the coinsurance, which is 20 percent of the allowable or approved charge for a product or service
  • I permit the pharmacy to release and collect my health information, and other information, as required (and as permitted by HIPAA regulations) from my healthcare providers and Medicare for the purpose of receiving payment from Medicare.
  • To communicate whether you clearly comprehend the course of treatment and plan of care
  • I understand that your authorization from the Product Setup and Delivery Form will be maintained and made available to Medicare and/or its representatives.

 

DMEPOS Supplier Standards (Medicare Only)

The products and/or services provided to you by Fruth Pharmacy are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g. honoring warranties, and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards.

Medicare DME – 016 – Appendix A – Patient Bill of Rights and Responsibilities
CORPORATE OFFICE • 4016 OHIO RIVER ROAD • POINT PLEASANT, WV 25550 • (304) 675-1612