Patient Financial Agreement

Proof of Delivery: The patient or responsible party ("I") acknowledges receipt/proof of delivery of the Durable Medical Equipment specified on this Standard Written Order. I do confirm on this day I am in receipt from Advanced Technology of Kentucky Inc. ("ATI") or an Advanced Technology of Kentucky Inc. affiliate ("Provider"), the product listed about and participated in the plan of care. I confirm I have also been provided (1) written and verbal instructions on proper use, care and maintenance of the product provided; (2) access to the Medicare Supplier Standards; (3) access to the Patient Bill of Rights; (4) Provider's Notice of Privacy Practices; (5) warranty information; (6) return policy; and (7) contact information for questions or complaints.

Refusal: I understand that I may refuse delivery of this product

Consent for Treatment: I consent to treatment by the Provider. I understand and agree that (1) my care is under the supervision and control of my attending physician; (2) my physician has prescribed the product and services delivered to me today as part of my treatment; (3) my physician has explained the risks, advantages, complications and alternatives to this product; (4) my physician has explained why this treatment is considered medically necessary as treatment for my condition; (5) the Provider's services do not include diagnostic testing, prescriptive rights and other functions pertaining to licensed physicians; and (6) only my physician is solely responsible for diagnosing and prescribing drugs, product and therapy for my condition or otherwise supervising and controlling my medical condition.

Assignment of Benefits: I consent to billing by the Provider and request any payment authorized by Medicare, Medicaid, supplemental insurance, Medigap, and/or other third-party insurance policies which is made on my behalf be directed to the Provider for the products delivered to me on this date.

Release of Information: I agree to provide all documents and information necessary for the Provider to obtain direct payment from Medicare, Medicaid and/or other third-party payers. I hereby authorize the release of my medical information to determine and obtain insurance benefits for products and services provided to me by the Provider. I authorize the Provider to appeal denied insurance authorizations or benefits on my behalf.

Financial Responsibility: I understand and agree that (1) I am financially responsible to the Provider for payment of applicable deductibles, co-insurance, or other amounts assigned by Medicare, Medicaid and other third-party payers as my financial responsibility; (2) I am financially responsible for any product or services delivered to me that are not reimbursed by Medicare, Medicaid and/or other third-party payers; unless otherwise prohibited by contract or law; (3) any amount owed will vary based on my insurance plan, whether my deductible has been reached, if I have co-insurance amounts, if an item is reimbursable by my plan, network status of my plan, and/or if I have secondary coverage; (4) I agree to transfer immediately to the Provider any payments made to me directly from Medicare, Medicaid, and/or other third-party payers for the products and/or services provided to me in whole or in part; and (5) if I am unable to pay my responsibility in full, I will contact the Provider at the information listed above to establish a payment plan and/or apply for income-based financial assistance.

Email and Cell Phone Acknowledgment: By providing my email and cell phone information I (1) authorize the Provider to contact me by those methods regarding the care and services I have received; (2) my information will not be used or sold for any other purpose; (3) portions of the correspondence may not be encrypted; therefore, the Provider cannot ensure the security of any information sent or received via email or text; and (4) will refer any questions regarding my rights to the Provider's Notice of Privacy Practices.