New Patient Packet | Affordable Medical

Locations

501 W. Kingshighway | Paragould, AR 72450 | (870)-239-0997

4707 E. Johnson Ave. | Jonesboro, AR 72401 | (870)-972-5900

308 W. Main St. | Walnut Ridge, AR 72476 | (870)-886-1260

Scope of Services

Respiratory Equipment

Oxygen Concentrators, Portable Oxygen Systems, Nebulizers, CPAP/BiPAP/RAD, Home Ventilators, Overnight Pulse Oximetry, Respiratory, Suction, Cough Assist Devices, Heated Humidity Systems, End-Tidal CO2 Monitoring, Pulse Oximetry Monitoring, HFCWO

Medical Equipment

Canes, Crutches & Walkers, Wheelchairs, Commodes, Bathroom Safety Aids, Lift Chairs, Hospital Beds & Mattresses, Patient Lifts & Trapeze Bars, Orthotics, TENS Units, Bedside Tables, Enteral Pumps, Gastric Suction, Power Mobility

Medical Supplies

Diabetic Testing Supplies, Incontinence Products, Urological Supplies, Tracheostomy Care, Enteral Nutrition, Wound Care,
PAP Supplies, DME Replacement Parts, Hospital Bed Accessories, Oxygen Supplies

Bariatric Equipment

Canes & Walkers, Wheelchairs, Commodes, Hospital Beds & Mattresses, Patient Lifts, Trapeze Bars,
Power Mobility

Geographic Coverage

We service, either portions or whole, the following counties in AR: Clay, Cleburne, Craighead, Crittenden, Cross, Greene, Independence, Jackson, Lawrence, Mississippi, Poinsett, Randolph, Sharp, St. Francis, White and Woodruff. And in MO: Butler, Carter, Dunklin, New Madrid, Oregon, Ripley, Pemiscot, Stoddard.

Action Statements

Affordable Medical has action statements to embody our vision, culture and goals; they are clinical excellence, reliable community partner, embrace innovation, professional pride, superior customer care.

Compliance and Commitment

Affordable Medical is committed to complying with all federal and state regulations. If you have any questions or concerns regarding any of our activities, please contact our office and ask to speak with the office manager.

Patient Complaint Procedure

All of our customers are very important to us. So that we can resolve any problems that arise in a timely and effective manner, we have developed the following patient compliant procedure.

When you have a concern, you can speak to the person delivering your equipment at the next visit.
If you do not want to wait to speak to the delivery person or if the issue you have involves our employee, you

can call our office and speak with a member of management at (870)-239-0997.
Once a complaint has been made, it must be reported to the HME Director by an employee within 24 hours. The

HME Director will research your concern in order to resolve all complaints and/or problems. You will be notified by telephone notification of the receipt of the complaint by our HME Director within 5 days and results of the investigation within 14 days in writing. If you feel the response is unsatisfactory, you have the right to contact Medicare at 1-800-MEDICARE (1-800-633-4227), Arkansas Department of Human Services (1-800-482-8988) or our company's accrediting organization, ACHC (1-855-937-2242). We welcome your candid comments as well as your assistance in helping us to continually improve our service(s) to our valued customers.

Patient’s Bill of Rights and Responsibilities

You have the right to:

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 of their financial responsibility.
Receive information about the scope of services that the organization will provide and any 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.
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.
Voice grievances/complaints regarding treatment or care of lack of respect of property, or recommend changes

in policy, personnel, or care/service without restraint, interference, coercion, discrimination, or reprisal.
Have grievance/complaints regarding treatment of care/service that is (or fails to be) furnished, or lack of respect

of property investigated.
Confidentiality and privacy of all information contained in the client/patient record and of Protected Health

Information (PHI).
Be advised of the agency's policies and procedures regarding the disclosure of client/patient records.
Choose a healthcare provider, including an attending physician, if applicable
Receive appropriate care/service without discrimination, in accordance with physician orders, if applicable.
Be informed of any financial benefits when referred to an organization.
Be fully informed of one's responsibilities.

You have the responsibility to:

Ask questions about any part of the plan of service or plan of care that you do not understand.
Protect the equipment from fire, water, theft or other damage while it is in your possession.
Use the equipment for the purpose for which it was prescribed, following instructions provided for use, handling

care, safety and cleaning.
Supply us with needed insurance information necessary to obtain payment for services and assume

responsibility for charges not covered. You are responsible for settlement in full of your account.
Be at home for scheduled service visits or notify us in advance to make other arrangements.
Notify us immediately of:

a. Equipment failure, damage or need of supplies.

b. Any change in your prescription or physician.
c. Any change or loss in insurance coverage.

d. Any change of address or telephone number, whether permanent or temporary.

e. Discontinued equipment or services.

Be respectful of the property owned by our company and considerate of our personnel.
Contact us if you acquire an infectious disease during the time we provide services.

NOTE: Please contact our office with any further questions about your rights under Medicare regulations.

For Our Customers With Special Electrical Needs

In order to request “priority service” from your utility provider in the event of a power outage follow these three easy steps to have your account flagged.

Obtain a letter from your doctor stating the need for priority service due to “life support” equipment.
Call your utility provider for your local district’s office address and mail the doctor’s letter to them.

Service, Delivery and Warranty

Business Hours

Our hours of operation are 9:00 A.M. to 5:00 P.M. Monday – Friday. 24-hour emergency service is available for equipment related emergencies that may arise after hours, on weekends and/or holidays.
Delivery
Deliveries are provided on purchases and/or rentals. It is preferable that routine and repeat orders be called in 24-48 hours in advance.

Rental Equipment

Customers are responsible for routine maintenance and cleaning of rented equipment according to the instructions provided during the initial set-up.
Purchased Equipment and Warranties
New equipment is subject to the manufacturer’s warranty. Refer to the warranty information provided to you at the time of purchase. All warranties will be honored under applicable state laws.

Service and Repair

Service or repair on equipment purchased from our company that is no longer covered by the manufacturer’s warranty will be subject to current labor charges. The customer will be informed of their responsibilities regarding the ongoing care and service of the equipment and will be provided with maintenance instructions and how to obtain any service required. All service and repair must be scheduled by calling the office during regular business hours.

Billing and Payment Policy

Customers are responsible for payment in accordance with our company’s terms. Assignment of benefits to a third party does not relieve the customer of the obligation to ensure full payment. Billing third party payers is not an obligation, but rather a service we offer if all necessary billing information and signatures are provided. All co-payments, deductibles and non-covered medical services must be paid for at the time of service. Your agreement to pay these expenses is a part of your contract with your insurance company. Failure on our part to collect these co-payments and deductibles would be a violation of our contract with your insurance company (and may be considered fraud). Please help us both comply with out contracts and the law by paying your portion of these expenses at the time of each visit.

Medicare

We may accept Medicare Part B assignment, billing Medicare directly for 80% of allowed charges and billing the beneficiary the 20% payment and any deductible. We offer Electronic Claims Transmission for billing non-assigned orders. Presentation of your Health Insurance Card is necessary. For some items, Medicare will choose to rent instead of purchase. Of these rentals, some are considered a “capped rental”, which means after 13 months of payment, those items are considered purchased for the beneficiary on behalf of Medicare. Any item that meets this criterion will discussed with the patient so they are aware.
Medicaid
We may provide equipment to Medicaid recipient upon verification and approval of coverage status and medical justification. Presentation of your State Beneficiaries Identification Card and personal ID are required.
Private Insurance
We may bill private insurance carriers upon verification and approval of coverage status and medical justification. You are responsible for providing our billing department with all necessary insurance information. You are also responsible for notifying us of any insurance changes. Presentation of your insurance card and personal ID are required. Remember, billing a third-party insurance does not guarantee payment. Financial responsibility remains with you, the patient.

Advance Medical Directives

Advance Medical Directives are legal documents that allow you to give directions for your future medical care. They can assist you in communicating your choices should you become physically or mentally unable to do so. Two types of advance directives are living wills and durable power of attorney. You can use advance directives to limit certain life prolonging measures when there is little or no choice of recovery. For example, you may wish to address:

CPR – Cardiopulmonary Resuscitation
IV Therapies
Feeding Tubes
Ventilators
Dialysis
Pain Relief

Your choices regarding your medical care should be discussed with your family, friends, physicians, clergy and attorney.

At Affordable Medical our employees are not certified to administer CPR. If a situation would arise, the employee is instructed to call 911, unless you, your physician or legal representative informs us otherwise. Please take the time to inform our office of any existing advance directives. Information regarding your advance directives can be disclosed by contacting our office and asking to speak with the manager. Should you have any questions regarding advance directives or our policy, please contact our office at the number shown on the front page of this handout.

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

YOUR RIGHTS
Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.
We will provide you with a paper copy promptly. Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the information on page 1.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by

sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting

www.hhs.gov/ocr/privacy/hipaa/complaints/
We will not retaliate against you for filing a complaint.

YOUR CHOICES
You have both the right and choice to tell us to

Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory

If you are not able to tell us your preference

For example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
We will never share or sell any of your information for

Marketing purposes
Sale of your information

Fund-raising

We will NEVER contact you for fund-raising efforts.

OUR USES AND DISCLOSURES

How do we typically use or share your health information? We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. (For more: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html )

Help with public health and safety issues

We can share health information about you for certain situations such as:

 Preventing disease
 Helping with product recalls
 Reporting adverse reactions to medications
 Reporting suspected abuse, neglect, or domestic violence
 Preventing or reducing a serious threat to anyone’s health or safety

Doing research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

 For workers’ compensation claims
 For law enforcement purposes or with a law enforcement official
 With health oversight agencies for activities authorized by law
 For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

 We are required by law to maintain the privacy and security of your protected health information.
 We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
 We must follow the duties and privacy practices described in this notice and give you a copy of it.
 We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Medicare DMEPOS Supplier Standards

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.
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. A supplier must have an authorized individual (whose signature is binding) sign the enrollment application for billing privileges.
4. A supplier must fill orders from its own inventory, or contract with other companies for the purchase of items necessary to fill orders. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or 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 and must maintain a visible sign with posted hours of operation. The location must be 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.
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 is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition see 42 CFR § 424.57 (c) (11).

12. A supplier is responsible for delivery of and must instruct beneficiaries on the use of Medicare covered items, and maintain proof of delivery and beneficiary instruction.
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 cost either directly, or through a service contract with another company, any 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 standards to each beneficiary it supplies a Medicare-covered item.
17. A supplier must disclose 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 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 for those specific products and services (except for certain exempt pharmaceuticals).
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. A supplier must meet the surety bond requirements specified in 42 CFR § 424.57 (d).
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 CFR § 424.516(f).
29. A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers.
30. A supplier must remain open to the public for a minimum of 30 hours per week except physicians (as defined in section 1848(j) (3) of the Act) or physical and occupational therapists or a DMEPOS supplier working with custom made orthotics and prosthetics.

DMEPOS suppliers have the option to disclose the following statement to satisfy the requirement outlined in Supplier Standard 16 in lieu of providing a copy of the standards to the beneficiary. The products and/or services provided to you by Affordable Home Healthcare 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://www.ecfr.gov. Upon request, we will furnish you a written copy of the standards.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new

notice will be available upon request, in our office, and or online. For further information about this Privacy Notice, please contact K.J. Spillman at 870-239-0997.

Emergencies and Natural Disasters

In case of an emergency or natural disaster that has caused an interruption in service or loss of electricity, please call our office as soon as possible. In case of an emergency or natural disaster that has you experiencing a medical emergency, call 911 immediately or go to the nearest hospital if possible. If you are in continued service with us and you have to leave your primary residence for an extended length of time, remember to take any of your necessary equipment and supplies and please notify our office of your current address and other contact information. We can always help to

provide service to you at a secondary location or assist you in finding a shelter if needed. We have enclosed on the following pages both a community resource guide and a list of items suggested by the U.S. Dept of Homeland Security for an emergency supply kit for your reference.

COMMUNITY RESOURCE GUIDE

Affordable Medical has compiled a list of frequently used resources within the community. Please use this guide to find any help you might need. For more information, visit www.arkansas211.org or call our Paragould office at 870-239-0997.

GENERAL INFORMATION

Department of Health & Human Services | 809 Goldsmith Road – Paragould, AR | 236-8723

ABUSE OF A PERSON

Adult Protective Services | 1-800-482-8049
Advocates for Nursing Home Residents | 1-888-311-2238

Child Protective Services | 1-800-482-5964
NEA Family Crisis Center | 870-933-9449
Victim Assistance Office | 239-9598

ALCOHOL ABUSE

Alcoholic Anonymous 2901 | W Washington Ave – Jonesboro, AR | 870-933-1518

Celebrate Recovery – East | 7th & Mueller Church of Christ – Paragould, AR | 236-6105

Celebrate Recovery – West | West View Baptist Church – Paragould, AR | 236-7195

Celebrate Recovery – South | Southside Community Church – Paragould, AR | 239-2271

CHAMBER OF COMMERCE

Jonesboro Chamber of Commerce | 1709 E Nettleton Ave – Jonesboro, AR | 870-932-6691

Paragould Chamber of Commerce | 300 W Court St – Paragould, AR | 236-7684

CHILD/FAMILY ASSISTANCE

Center for Fathers & Families | 4100 Linwood Dr – Paragould, AR | 236-1323

Childcare Assistance | 1-800-322-8176

Lifehouse Ministries | 4100 Linwood Dr – Paragould, AR | 236-5807

ELECTRICAL SERVICE PROVIDERS

Paragould LWC | 1901 Jones Road – Paragould, AR | 239-7700

EMERGENCY INFORMATION

Compassion Outreach | 1000 S 7th St – Paragould, AR | 239-9442

Mission Outreach | 901 E Lake St – Paragould, AR | 236-8080

Red Cross | 870-932-3212
United Way of NEA | 870-935-3658

FINANCIAL HELP

Crowley's Ridge Development Council | 901 E Lake St – Paragould, AR | 239-3531

FOOD PROGRAMS

Angel Food Ministries | 404 W Main St – Paragould, AR | 870-289-8541
Griffin Memorial UMC Food Pantry | 524 E Court – Paragould, AR | 236-2060

Higher Trails Cowboy Church | 9728 Hwy 358 W – Paragould, AR | 476-1685

Meals on Wheels | 120 W Highland – Paragould, AR | 236-3903
Senior B.E.E.S (Senior citizens only) | 123 N 12th St – Paragould, AR | 239-4093

The Witt House | 501 W Garland St – Paragould, AR | 239-8541
West View Baptist Church | 701 W Morgan – Paragould, AR | 236-7195

HEALTHCARE INFORMATION

Crowley's Ridge Rural Healthcare | 1 Centre 1 N Suite #601 – Paragould, AR | 215-0341

Medicaid Program | 1-800-275-1131
Medicare Program | 1-800-633-4227
Mission Outreach Charitable Clinic | 1 Medical Dr – Paragould, AR | 236-8080

HOUSING & ASSISTED LIVING

Belle Meade Nursing Home | 2200 Chateau Blvd – Paragould, AR | 1-800-676-1690

Paragould Housing Authority | 612 Canal St – Paragould, AR | 239-8084

Sunshine Manor | 3001 Linwood Drive – Paragould, AR | 236-3446

LEGAL AID

Arkansas Legal Aid | 202 Walnut St – Newport, AR | 1-870-523-9892

CASA | 120 N 2nd St – Paragould, AR | 240-8955
Legal Services of NEA | 714 S Main St – Jonesboro, AR | 870-972-9224

MENTAL HEALTHCARE

Arkansas Counseling Associates | 100 N Rockingchair Rd Suite #2 – Paragould, AR | 335-9617

St Bernard's Behavioral Health | 2712 E Johnson Ave – Jonesboro, AR | 870-932-2800

SENIOR CITIZEN ORGANIZATIONS

East Arkansas Area Agency on Aging | 2005 E Highland – Jonesboro, AR | 870-972-5980

Senior B.E.E.S. | 121 N 12th St – Paragould, AR | 239-4093
Senior B.E.E.S. | 100 W Walnut – Paragould, AR | 239-8739

SUBSTANCE ABUSE

Mid-South Health Systems | 2707 Browns Lane – Jonesboro, AR | 870-972-4000

Alcohol & Drug Abuse Prevention | 1-501-686-9866