Dear New Patient,

Welcome and thank you for choosing Aspire Products, LLC for your healthcare needs! Enclosed in this packet you will find the following documents:

* THESE DOCUMENTS MUST BE COMPLETED, SIGNED ANDRETURNED TO Aspire Products, LLC:

Patient’s Rights and Responsibilities * Patient

Agreement/Information Release*

Delivery Authorization *

Patient Information Release * Patient

Acknowledgement of Receipt *

PLEASE RETAIN THESE DOCUMENTS FOR YOUR RECORDS:

DMEPOS Medicare Supplier Standards

Notice of Privacy Practices

Patient Complaint/Grievances Policy

Billing and Reimbursement Practices

Emergency Policies & Procedures for Patients

Community Resource List

Please complete and sign the Patient’s Rights and Responsibilities, Patient Agreement/Information Release, Delivery Authorization, and Patient Acknowledgement of Receipt of documents at your earliest convenience and return them to us via fax @ 800-861-2090 or email sales@emst150.com.

In the future, if there are any changes to your contact information, address, insurance or doctors, please update Aspire Products immediately.

We pride ourselves on our outstanding customer service, products and care. Please contact us with any questions or comments about your supply needs or service. Our hours are Mon - Fri - 10am -4pm. Our toll free customer service line is 800-596-7220 and is open 24 hrs a day. Take a moment to browse our website: www.emst150.com to see our full product offerings.

Thank you for choosing Aspire Products, LLC. We look forward to working with you!

Sincerely, Aspire Products, LLC

101 VFW Rd., Suite 2C, Cedar Point NC 28584 toll free- 800-596-7220, fax-800-861-2090

www.emst150.com

PATIENT’S RIGHTS AND RESPONSIBILITIES

As a patient you have the right to:

1. Choose your provider of home medical supplies and equipment. You also have the right to refuse service within theconfines of the law and be given information concerning consequence of refusing services.

2. Receive a timely response from Aspire Products, LLC regarding your request for home medical supplies andequipment.

3. Be given appropriate service without discrimination due to diagnosis, race, creed, color, religion, sex, national origin,sexual preference, handicap, disability or age.

4. Be treated with courtesy and respect by all Aspire Products, LLC personnel who provide service to you, in addition tobeing free from physical and mental abuse, neglect and exploitative practices.

5. Be given proper identification by name and title of all Aspire Products, LLC personnel who provide service to you.6. Be given all necessary information, in a manner you can understand, so that you will be able to give informed consent

for your services.7. Receive complete privacy and confidentiality with regard to your condition, diagnosis, records, files, and any other

personal health information or pertinent data as mandated by federal HIPAA regulations.8. Access and review your records as mandated by federal HIPAA regulations.9. Be involved in the planning and ordering process in addition to being notified of any changes in your medical

equipment and/or supply services.10. Register any complaints regarding services with us and/or appropriate federal and state agencies without fear of

discrimination or unreasonable interruption of services. Patients may call our office with any complaints, grievances,and/or recommendations for change. Patients may also call Medicare at1-800-633-4227. (Please see the Patient Complaints/Grievances Policy included with the information packet forfurther information on our complaint policy and procedure.)

11. Rent or purchase inexpensive/routinely purchased Medicare items.12. Patients also have the right to refuse any service.

As a patient you have the responsibility to:

1. The patient should promptly notify the Aspire Products, LLC of any equipment failure or damage.2. The patient is responsible for any equipment that is lost or stolen while in their possession and should promptly notify

Aspire Products, LLC in such instances.3. The patient should promptly notify Aspire Products, LLC of any changes to their address or telephone.4. The patient should promptly notify the Aspire Products, LLC of discontinuance of use.5. The patient should notify the Aspire Products, LLC of discontinuance of use.6. Except where contrary to federal or state law, the patient is responsible for any equipment rental and sale charges which

the patient’s insurance company/companies does not pay.7. Follow instructions on the care, use and maintenance of equipment and return rental equipment in good condition.8. Show respect and consideration for Aspire Products, LLC personnel and property.9. Provide feedback to Aspire Products, LLC regarding service needs and expectations.10. Read, complete & sign the Notice of Privacy Practices included with this information packet.11. Request further information concerning anything you do not understand.

X____________________________________________________ Signature of Patient, Parent or Guardian Date

101 VFW Rd., Suite 2C, Cedar Point NC 28584 toll free- 800-596-7220, fax-800-861-2090

www.emst150.com

PATIENT AGREEMENT Health Insurance I.D. # Patient Name

Address « Telephone #

Healthcare Product and or Service Effective Date

REQUEST FOR PROVISION OF SERVICES I understand that by signing this agreement, I indicate my wish to purchase health care products or service or both from Aspire Products, LLC.

INDICATION OF MEDICAL RESPONSIBILITY I understand that I am signing under the supervision and control of my attending physician. I understand that Aspire Products,LL services do not include diagnostic, prescriptive or other functions typically performed by licensed physicians, and that my physician is solely responsible for diagnosing and prescribing drugs, supplies, equipment and services for my condition and otherwise supervising and controlling my medical care.

RELEASE OF INFORMATION I authorize my insurer(s), and any other third party payor who provides me with coverage, to disclose to Aspire Products, LLC any information regarding such coverage, including, but not limited to, payments made by such insurer(s) or third party payor(s) to me, for home healthcare products or services rendered to me by Aspire Products, LLC, and the scope and extent of coverage available from time to time. I authorize all medical personnel to provide information to Aspire Products, LLC concerning my medical history as it may relate to my home services and health care product needs. If my primary insurance changes, I agree to notify Aspire Products, LLC.

ASSIGNMENT OF BENEFITS I authorize Aspire Products, LLC to request on my behalf, and to collect directly, all public and private insurance coverage benefits due for products and services supplied by Aspire Products, LLC. In the event payments for insurance benefits are made directly to me, the payee, I will endorse all checks for payment to Aspire Products, LLC. I accept all responsibility for overpayments per statement.

EXTENDED MEDICARE ASSIGNMENT I certify that the information given by me for payment under Medicare (Title XVIII of the Social Security Act) and/or other medical insurance is correct.

1. The patient, if physically and mentally competent, must sign on his/her behalf. If he/she cannot sign for himself/herself, a representative payee as designated by the Social Security Administration, or a legally appointed guardian, may sign. The source of the signatoree’s authority should be stated (e.g. “Social Security appointed Representative Payee,” or “court appointed guardian,” etc.). 2. This form is used in lieu of the patient’s signature on the “Request for Payment” HCFA-1500 (I-84) and is therefore an extension of that form. Anyone who misrepresents or falsifies essential information in making Medicare claims may, upon conviction, be subjected to fine and imprisonment under Federal law. Furthermore, in signing, the beneficiary authorizes any holder of medical or other information about himself/herself to release to the Social Security Administrationor its intermediaries or carrier any information needed to process related Medicare claims. He/she further permits a copy of the authorization to be used in place of original.3. On assigned claims, the provider agrees to accept the Medicare carriers’ allowable amount as the full charge for covered services; the patient is responsible for the deductible, co-insurance and non-covered services. This authorization may be cancelled by mutual agreement of the provider and customer at any time by written notice to the Medicare Center.

I request payment under the Medical Insurance Part of MEDICARE be made directly to Aspire Products, LLC for service furnished me during the effective period of this authorization. I have read and I agree to the release of information as specified in Paragraph 2 above.

The undersigned certifies that he/she has read the foregoing and received a copy. The undersigned also certifies that he/she is the patient, or is duly authorized by the patient as patient’s general agent, to execute the above and accept its terms.

NOTE: A copy of this Agreement and Consent shall be considered the same as an original.

Manager: Telephone: 800-596-7220

X____________________________________________________________________________________ Patient/Spouse/Guarantor/Guardian Signature Relationship to Patient Date

RETURN THIS COPY- signed and dated to Aspire Products, LLC

101 VFW Rd, Suite 2C, Cedar Point, NC 28584toll free- 800-596-7220, fax-800-861-2090

www.emst150.com

DELIVERY AUTHORIZATION FORM**

Patient’s Name: ____________________________

If I am not home, please do not leave delivery.

I understand that if I do not authorize Aspire Products to leave my delivery or if I do not give an alternative delivery option below that I will not be sent a shipment until the following month. As an alternative, you may also schedule a pick-up at our Cedar Point location if you miss your delivery.

OR

If I am not home, I authorize to leave the delivery as described below:

** Orders can also be picked up at our office at your convenience, please contact Customer Service for more details.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

X________________________________________________

Signature of Patient, Parent or Guardian Date

RETURN THIS COPY- SIGNED AND DATED- TO Aspire Products, LLC

101 VFW Road, Suite 2C Cedar Point NC 28584252-764-2842 (local), 800-596-7220 (toll free), 800-861-2090 (fax)

www.emst150.com

PATIENT ACKNOWLEDGEMENT OF DOCUMENTATION RECEIPT

I, the undersigned, acknowledge that I have received, read and understand the following documents

provided to me from Aspire Products, LLC:

Patient’s Rights and Responsibilities *

Patient Agreement/Information Release *

Delivery Authorization *

Patient Acknowledgement of Receipt *

DMEPOS Medicare Supplier Standards

Notice of Privacy Practices

Patient Complaint/Grievances Policy Billing

and Reimbursement Practices Emergency

Policies & Procedures for Patients

Community Resource List

* I have completed the documents (marked with an *) required by Aspire Products, LLC in orderto initiate the services I’ve requested.

Patient Name _________________________________________________________________

X______________________________________________________ Patient or Patient Guardian/Caregiver Signature DATE

RETURN THIS COPY- SIGNED AND DATED- to Aspire Products, LLC

TOLL$FREE:$800-596-7220

101 VFW Rd. Suite 2C, Cedar Point NC 28584toll free- 800-596-7220, fax-800-861-2090

www.emst150.com

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$REQUIREMENTS$AND$CANNOT$

CONTRACT$WITH$AN$INDIVIDUAL$OR$ENTITY$TO$PROVIDE$LICENSED$SERVICES.$$

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. AN$AUTHORIZED$INDIVIDUAL$(ONE$WHOSE$SIGNATURE$IS$BINDING)$MUST$SIGN$THE$APPLICATION$FOR$BILLING$PRIVILEGES.$$

4. A$SUPPLIER$MUST$FILL$ORDERS$FROM$ITS$OWN$INVENTORY,$OR$MUST$CONTRACT$WITH$OTHER$COMPANIES$FOR$THE$PURCHASE$OF$ITEMS$

NECESSARY$TO$FILL$THE$ORDER.$A$SUPPLIER$MAY$NOT$CONTRACT$WITH$ANY$ENTITY$THAT$IS$CURRENTLY$EXCLUDED$FROM$THE$MEDICARE$

PROGRAM,$ANY$STATE$HEALTH$CARE$PROGRAMS,$OR$FROM$ANY$OTHER$FEDERAL$PROCUREMENT$OR$NONCPROCUREMENT$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.$THIS$STANDARD$REQUIRES$THAT$THE$LOCATION$IS$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$CONDUCT$ONCSITE$INSPECTIONS$TO$ASCERTAIN$THE$SUPPLIER’S$COMPLIANCE$WITH$THESE$

STANDARDS.$THE$SUPPLIER$LOCATION$MUST$BE$ACCESSIBLE$TO$BENEFICIARIES$DURING$REASONABLE$BUSINESS$HOURS,$AND$MUST$MAINTAIN$A$

VISIBLE$SIGN$AND$POSTED$HOURS$OF$OPERATION.$$

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$SUPPLIER$MUST$AGREE$NOT$TO$INITIATE$TELEPHONE$CONTACT$WITH$BENEFICIARIES,$WITH$A$FEW$EXCEPTIONS$ALLOWED.$THIS$STANDARD$

PROHIBITS$SUPPLIERS$FROM$CONTACTING$A$MEDICARE$BENEFICIARY$BASED$ON$A$PHYSICIAN’S$ORAL$ORDER$UNLESS$AN$EXCEPTION$APPLIES.$$

12. A$SUPPLIER$IS$RESPONSIBLE$FOR$DELIVERY$AND$MUST$INSTRUCT$BENEFICIARIES$ON$USE$OF$MEDICARE$COVERED$ITEMS,$AND$MAINTAIN$PROOF$

OF$DELIVERY.$$

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$DIRECTLY,$OR$THROUGH$A$SERVICE$CONTRACT$WITH$ANOTHER$

COMPANY,$MEDICARECCOVERED$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$SUPPLIER$STANDARDS$TO$EACH$BENEFICIARY$TO$WHOM$IT$SUPPLIES$A$MEDICARECCOVERED$ITEM.$$

17. A$SUPPLIER$MUST$DISCLOSE$TO$THE$GOVERNMENT$ANY$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$IMPLEMENTING$REGULATIONS.$$

22. ALL$SUPPLIERS$MUST$BE$ACCREDITED$BY$A$CMSCAPPROVED$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$OF$THOSE$SPECIFIC$PRODUCTS$AND$SERVICES$(EXCEPT$FOR$CERTAIN$EXEMPT$

PHARMACEUTICALS).$IMPLEMENTATION*DATE*,*OCTOBER*1,*2009*$23. ALL$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. MUST$MEET$THE$SURETY$BOND$REQUIREMENTS$SPECIFIED$IN$42$C.F.R.$424.57(C).$IMPLEMENTATION*DATE,*MAY*4,*2009*$27. A$SUPPLIER$MUST$OBTAIN$OXYGEN$FROM$A$STATEC$LICENSED$OXYGEN$SUPPLIER.$$

28. A$SUPPLIER$MUST$MAINTAIN$ORDERING$AND$REFERRING$DOCUMENTATION$CONSISTENT$WITH$PROVISIONS$FOUND$IN$42$C.F.R.$424.516(F).$$

29. DMEPOS$SUPPLIERS$ARE$PROHIBITED$FROM$SHARING$A$PRACTICE$LOCATION$WITH$CERTAIN$OTHER$MEDICARE$PROVIDERS$AND$SUPPLIERS.$$

30. DMEPOS$SUPPLIERS$MUST$REMAIN$OPEN$TO$THE$PUBLIC$FOR$A$MINIMUM$OF$30$HOURS$PER$WEEK$WITH$CERTAIN$EXCEPTIONS$$

EMERGENCY POLICIES & PROCEDURES FOR PATIENTS

The goal at Aspire Products, LLC is to provide services to our clients as promptly and efficiently as possible. However, safety must be a priority in consideration of our clients and staff alike.

In the case of an emergent event that could cause interruption of services, such as natural disaster or inclement weather, Management and Customer Service will attempt to work with clients scheduled to receive a delivery within the specific time frame of the event to coordinate alternate arrangements, such as early delivery or customer pickup, to ensure supplies can be received in a safe and timely manner.

If such an event should occur, deliveries will have to be prioritized to ensure the health and safety of high priority clients will not be compromised (i.e. feeding pump patients). This prioritization is as follows:

PRIORITIZATION OF DELIVERY:

1. DURABLE MEDICAL SUPPLIES/EQUIPMENT

INCLEMENT WEATHER:

In the case of inclement weather (i.e., severe snowstorm, thunderstorm, hurricane, etc.), deliveries will be pushed up in attempt to deliver to as many clients as possible before the storm is in full effect. Clients whose routes will be delivered ahead of time will receive an automated voice message informing them that the early delivery will take place due to the inclement weather. It is then the responsibility of the client and/or client’s caregiver to call Customer Service to make an alternate arrangement if they will not be able to accept this early delivery.

If Aspire Products, LLC is unable to deliver products to clients safely, and/or no alternate arrangements are made, it is agreed that the clients’ deliveries will be made as soon as safety conditions are restored and/or deemed possible by Management.

EVACUATION DUE TO AN EMERGENT EVENT

A wide variety of emergencies, both man-made and natural, may require Aspire Products, LLC to be evacuated. These emergencies include - fires, explosions, floods, earthquakes, hurricanes, tornadoes, toxic material releases, radiological and biological accidents, civil disturbances and workplace violence. In the case in which any of the above mentioned events occur and Aspire Products, LLC is to be evacuated, The Company will send an automated message to the effected clients remotely. Clients will receive the automated notification -within 12 hours after the event- informing the client that an emergent event has occurred and services may not be able to be provided unless alternate arrangements are made. It is then the responsibility of the client or client’s caregiver to call the number provided in the message to pursue the attempt to make such an arrangement.

If the client and Aspire Products, LLC are unable to successfully make an alternate arrangement for their delivery, it is agreed that the client’s delivery will be made as soon as safety conditions are restored and/or deemed possible by Management.

The ability for Aspire Products, LLC to assist in these situations will take into account environmental conditions, safety concerns and any restrictions placed on travel by federal, state or local authorities.

FEEDING PUMP EMERGENCIES - Not Applicable

Aspire Products, LLC has personnel available 24 hours a day, 7 days a week for emergencies involving enteral feeding pump malfunction. For emergencies occurring after business hours, calls are directed to a live answering service that has procedures for contacting TMed personnel. When a call is received from a patient/caregiver, a service/repair technician or other trained staff will determine the problem. If the problem cannot be solved over the phone with patient/caregiver, then another pump will be delivered as soon as possible, with consideration of the time of day and patient convenience, but no later than the following day if the call is received at night. If patient/caregiver prefers, they may call the pump manufacturer direct at a toll free number provided to all pump patients. This is a 24-hour/7day-tech support line.

IN THE EVENT OF INCLEMENT WEATHER deliveries are prioritized, and emergency deliveries will be made via a vehicle equipped with 4-wheel drive. Additional resources would be Local Fire or Police for assistance, if needed.

IN THE EVENT OF A NATURAL OR MAN-MADE DISASTER where the power failure is expected to last for more than a day or two, Aspire will assist the patient/client to the extent possible. Enteral feeding pumps are battery powered. Information about the battery operation time and charging the battery is contained in the Operator’s Manual provided with each pump. Assistance may consist of exchanging the pump for a fully charged one or removing the pump, recharging it and returning it to the patient/client.

NOTICE OF PRIVACY PRACTICES As Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance

Portability and Accountability Act of 1996 (HIPAA)

EFFECTIVE SEPTEMBER 18, 2013 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR PROTECTED HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACYThe terms of this notice apply to all records containing your protected health information that are created, received,maintained or transmitted by our Company, our Business Associates and their subcontractors. We reserve the right to reviseand amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your recordsour company has created or maintained in the past, and for any of your records we may create, receive, maintain or transmitin the future. Our Company will post a copy of our most current notice in our offices in a prominent location and on ourwebsite. You may request a copy of our most current notice by telephone, in writing or by e-mail.

B. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Gail Wiley- President,(800-861-2090, 252-764-2842, 101 VFW Rd, Cedar Point NC 28584.

C. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION IN THE FOLLOWING WAYS

The following categories describe different ways in which we may use and disclose your identifiable health information. Except for the purposes described below, any other uses or disclosures of protected health information not covered by this notice to include for the purposes of marketing or disclosures that would constitute a sale of your protected health information and or the laws that govern us will only be made with your written authorization.

1. Treatment. Our company may use and disclose your protected health information for your treatment and to provide you withtreatment related services. For example, we may disclose health information to doctors, nurses, or other personnel, including peopleoutside our office / company, who are involved in your medical care and need the information to provide you with medical care.

2. Payment. Our company may use and disclose your protected health information in order to bill and collect payment for the servicesand items you receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits and we mayprovide your insurer with details regarding your services and home healthcare items to determine if your insurer will cover, or pay for,these services and items. We also may use and disclose your protected health information to obtain payment from third parties thatmay be responsible for such costs, such as family members. Also, we may use your protected health information to bill you directly forservices and items not covered by health insurance.

3. Health Care Operations. Our company may use and disclose your protected health information to operate our business. Asexamples of the ways in which we may use and disclose your information for our operations, our company may use your healthinformation to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for ourcompany.

4. Business Associates. Business Associates are parties with which we conduct business in order to provide you with our serviceswhich include but are not limited to provisions of medical equipment and its assembly, medical supplies, home delivery service ofequipment and supplies, and medical billing to your health insurance payer, yourself or other designated parties. Our company mayuse and disclose your protected health information to Business Associates. Business Associates will be provided only with theminimum of health information necessary in order for them to perform the activities of their business that they conduct on our behalf.

5. Appointment Reminders. Our company may use and disclose your protected health information to contact and remind you ofvisits/deliveries.

6. Health-Related Benefits and Services. Our company may use and disclose your protected health information to inform you ofhealth-related benefits or services that may be of interest to you.

7. Release of Information to Family/Friends. Our company may release your protected health information to your family, a relative, aclose friend or any other person you identify as involved in helping you pay for your health care, or who assists in taking care of you,unless you object. Please see “YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION” section of this Notice ofPrivacy Practices for further information.

8. Disclosures required by law. Our company will use and disclose your protected health information when we are required to do soby federal, state or local law.

PATIENT COMPLAINTS/GRIEVANCES POLICY

Patients lients and are i ers a e t e ri t to a e all omplaints eard, in esti ated and ene er possi le, resol ed Aspire Products, LLC promotes open ommuni ation et een patients parents uardians and sta

e Compan respe ts ot t e patients ri ts and t e need or e e ti e ommuni ation

Patients lients are ree to oi e omplaints or rie an es re ardin poli ies or ser i es and re ommend an es it out oer ion, dis rimination, reprisal or unreasona le interruption o ser i es e omplaint

pro ess in ludes inta e, in esti ation, orre ti e a tion as appli a le, omplaint resolution, and ollo -up Patients re ei e re uired do umentation a out e Compan s omplaint-resolution pro ess it in t eir inta e do umentation

Aspire re ei es, in esti ates and responds to omplaints and re ommendations re ei ed rom patients lients e patient s ustomer s re ord must do ument all ommuni ation, si ned and dated a sta mem er

A patient lient ma ile a omplaint or rie an e allin ustomer ser i e at 800-59 -7220 or e omplaint ma also e su mitted in ritin to t e Compan President, ail Wile at t e

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e omplainant ill e noti ied it in 5 usiness da s o re eipt t at t e omplaint as een re ei ed and is ein in esti ated e Compan ill initiate an in esti ation inter ie in sta in ol ed, re ie in

deli er i or tio , e in patient s ile in ludin tr c i d ot er do umentations ne essar , t e patient and or are i er ill e onta ted or more in ormation ollateral sour es are to e onta ted or in ormation, t e patient ill e noti ied and in ormation release orms ill e o tained

Wit in 14 usiness da s, a ritten response o t e out ome o su in esti ation or t e omplaint resolution ill e sent to t e patient

A omplete report o t e initial omplaint and su se uent in esti ation and resolution is to e ept t e Aspiure Products, LLC in a se ure ile, and a summar is do umented in t e patient s ile

Patients ma all our a reditin or ani ation, AC C, to ile a omplaint or uestion a out Aspire Products, LLC as an or ani ation i deemed ne essar ACHC Complaint Hotline (855) 937-2242

Patients ma also all ort C ro i i isio o e t er ice e u tio C t it i C or edi are at 1-800- 33-4227 to re ister omplaint, i deemed ne essar

te: _________________________________

Please describe your compliment/concern: _________________________________________________________________

_______________________________________________________________________________________________________________ ___________________________________________________________________________________________________ ____________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ ___________________________

____________________________________________________________________________________

********************OFFICE USE ONLY********************

Action Taken:________________________________________________________________________________________________

_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ __________________________________________________________________ _____________________________________________ _______________________________________________________________________________________________________________ ____________________________________________________________________________________________________ ___________

_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________

Action Date: _____________________________________________________

Address: ___________________________________________________________________________________

City, State: ______________________ Telephone Number: _____________

Patient Communication Form

We genuinely strive to provide the highest quality health care services to all our patients. That’s why your concerns are our concerns. To ensure that our services meet your total satisfaction, we ask you to describe any complaint, problem, concern or compliment you may have.

Our Compliance Officer will ensure that each concern is researched in order to resolve all complaints and/or problems.

We appreciate your candid comments as well as your assistance in helping us to continually improve our service(s) to our valued patients.

Name:Medicare Patient_________________________________________________Da

4

Aspire Products' Financial Policy

All new equipment setups going on account require prior verification of insurance coverage

before equipment is setup. If this is not possible due to a weekend or other after hours setup,

verification must be done on the next business day.

· We do not guarantee coverage of, or payment of insurance claims.

· We do not guarantee any time frame for processing of insurance claims or subsequent

billing from our office. It will be done in as timely a manner as possible.

Insurance CoveragePatient’s Responsibility:

· Provide us with all insurance information necessary to file your claim

· Notify our office of any changes or loss of insurance coverage

· Pay all deductible and balance remaining after secondary insurance is filed

· Patient is responsible for payment in full of all claims not covered by insurance. You will

be informed before delivery if we know that an item is not covered and assignment will

not be accepted.

Medicare Claims

If Medicare is your insurance carrier and denies payment, you will be notified. At that time, if

you wish to keep the equipment, it may be converted to private rental. If Medicare assignment

is accepted, at no time will the charges on those items be more than the yearly deductible plus

the 20% that Medicare does not pay. In many cases, the deductible amount and the 20% is

paid by other insurance. We will follow through with the appeal process on Medicare claims

that are denied. This will be done on non-assigned claims at the patient’s request.

The patient is also advised that:

· Inexpensive, routinely purchase durable medical equipment may be rented or

purchased.

· There will be a minimum of one-month rental on all equipment rentals.

· Rental charges will be assessed until we are notified to pick up the equipment.

· Any charges will be assessed until we are notified to pick up the equipment.

· Any charges incidental to the use or operation of the equipment (such as electricity) is

the responsibility of the patient.

· There is no charge for delivery or pickup of rental equipment.

· All claims, assigned or non-assigned, will be filed on behalf of the patient.

Billing and Payment Policy

Our mission at Aspire Products, LLC is to offer our clients outstanding service and simplify the way that medical supplies are ordered and received. Aspire Products, LLC customer service representatives help clients determine their insurance coverage and bill the insurance(s) on their behalf. Patients are

responsible for payment in accordance with our company’s terms. Assignment of Benefits to a third

party does not relieve the patient of the obligation to ensure full payment. Billing third party is not an

obligation, but rather a service we offer if all necessary billing information and signatures are provided.

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.

Medicaid

We may provide equipment to Medicaid recipients 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. Presentation of your insurance card and personal ID required.

Managed Care

We will provide equipment upon approval and authorization from the managed care representative.

Presentation of your insurance card may be necessary. Remember, billing a third party insurance

DOES NOT guarantee payment. Financial responsibility remains with you, the patient.

COMMUNITY RESOURCE LIST

FIRE CEDAR POINT FIRE.

252-393-8301

POLICE SWANSBORO POLICE DEPT.

910-326-5151

HOSPITAL WESTERN CARTERET MED

CENTER (252) 393-6543

AMBULANCE (910) 326-5132

COUNCIL OF AGING (910) 326-4356

NATIONAL DOMESTIC VIOLENCE HOTLINE

http://www.ndvh.org/

1-800-799-SAFE(7233)

NC BATTERED WOMEN'S HOTLINE (919) 956-9124

ELDER ABUSE HOTLINE 1-800-922-2275

CHILD ABUSE HOTLINE (24 hours a day)

1-800-4-A-CHILD(1-800-422-4453)

DISABLED PERSONS PROTECTION COMMISSION www.mass.gov/dppc 1-800-426-9009

ANIMAL ABUSE HOTLINE www.mspca.org 1-800-628-5808

VISITING NURSE ASSOCIATION www.vnaa.org NHRMC homecare

910-259-1224

MEALS ON WHEELS mowaa@mowaa.org

White OAK Outreach910-326-1855

NUTRITION PROGRAM LOCATOR www.eldercare.gov (800) 677-1116

OXYGEN: Skubinna HOME MEDICAL Phone: (910) 325-1300

101 VFW RoadSuite 2C

Cedar Point, NC 28594

Phone: (252)764-2842 F ax (800)861-2090

DME REFERRAL FORM

Date: Name of Facility:

Referral Name: Phone #:

PATIENT DEMOGRAPHICS:

First Name: Last Name: M.I. Phone:

Street Address: City: State: Zip:

DOB: Sex: M F Social Security #:

Emergency Contact Phone:

Address: Email Address:

INSURANCE INFORMATION:

Primary Insurance: Medicare Medicaid Other Secondary Insurance: Medicare Medicaid Other

Name: Name:

Address: Address:

Phone: Phone:

Policy #: Group ID #: Policy #: Group ID #:

DIAGNOSIS or ICD10 CODES

1. 2. 3. 4.

EQUIPMENT / SUPPLIES NEEDED: (CHECK ITEMS)

EMST150 Expiratory Muscle Strength Device

PHYSICIANS DEMOGRAPHICS:

Physician Name: NPI #:

Street Address: City: State: Zip:

Contact: Phone: Fax:

Please return via fax (800) 861-2090or e-mail to sales@emst150.com

Notes: