Return to C & R Medical Supplies homepage
Resource Center
Medicare & Insurance Guide
Glossary of Medical Terms
Best of Medical Websites
Help for Patients and Caregivers
Return to C&R Medical Supplies homepage Customer Service Online Catalog Qualifications Become a Patient
About Us
Extra Large Font Size Large Font Size Normal Font Size
Locate Us
Contact Us
Product Categories
Our Location
2908 SE Loop 820
Fort Worth, TX 76140

Toll-Free: 877.551.9328
Local: 817.590.8166
Fax: 817.590.8277
View a map to our location

New Patient Paperwork

 

Patient Information:

Alt Phone:
Email:

Referral Information:

First Name
Last Name
Phone Number
Fax
Email Address

Company

How did you hear about us?

Insurance Information:

Primary Insurance:
Primary Insured:
ID #: Group #:
Insurance Address:
City: State: Zip:
Insurance Phone #:
 
Secondary Insurance:
Primary Insured:
ID #: Group #:
Insurance Address:
City: State: Zip:
Insurance Phone #:

Diagnosis:


Other

Physicians Information:

Physicians Name:
NPI #:
Phone: Fax:
Address:
City: State: Zip:

Customer's Bill of Rights:

Our commitment is to provide quality medical supplies to all individuals without regard to race, color, religion, national origin, gender, age, sexual orientation, or disability.

• Benefits

You have a right to be provided information on what you are eligible to receive as well as what the company is providing. Within allowances established by your insurance carrier, you are entitled to request a specific manufacturer and brand/make/model of product.

You will be called on a monthly basis in regards to your supply shipment. You have a right to accept or refuse all or any part of your shipment.

You may view our products and services online at www.CandRMedical.com, or you may request a company brochure or any other information by calling the company at (817) 590-8166 or toll-free at 1-866-676-3928.

• Complaints

The patient has the right to freely voice grievances and recommend changes in care or services without fear of reprisal or unreasonable interruption of services. Service, equipment, products, and billing complaints will be communicated to management and upper management.

Complaints may be reported either to the Secretary of Health and Human services, or to our designated privacy officer:
Randy Smith
817-590-8166
1225 Precinct Line Rd., Suite M
Hurst, TX 76053

These complaints will be documented on the Beneficiaries Complaint Log, and completed forms will include the patient’s name, address, telephone number, health insurance claim number, a summary of the complaint, the date it was receive, the name of the person receiving the complaint, and a summary of actions taken to resolve the complaint.

All complaints will be handled in a professional manner. All logged complaints will be investigated, acted upon, and responded to in writing or by telephone by a manager within a reasonable amount of time after the receipt of the complaint. If there is no satisfactory resolution of the complaint, the next level of management will be notified progressively and up to the CEO of the company.

The patient will be informed of this complaint resolution protocol at the time of set-up of service.

• Company Hours

You have a right to be informed of the operational hours of the company and of how to reach company personnel after-hours for issues such as incorrect product received, out of product, or emergency repairs needed.

Company Hours: Monday-Friday 8:00am-4:00pm
Company Address: 1225 Precinct Line Road, Suite M
Hurst, TX 76053
Company Phone: (817) 590-8166 or toll-free 1-866-676-3928
Company Fax: (817) 590-8277
After Hours Emergency Contact: (817) 239-8052 or (319) 329-3647

• Billing

Individuals have the right to receive a copy of the Explanation of Benefits (EOB) to ensure that they have been appropriately billed for the services received.

• Privacy/Confidentiality

Individuals have a right to find out if the information to be disclosed to the payer would be anything other than demographics, diagnosis, type of supply, time and length of need, and cost.

Individuals have a right to know that confidentiality and privacy practices will be implemented in a professional manner and in accordance with law and regulation (HIPAA, etc.).

The information that you provide may be subject to outside review, when required by law, for appropriate billing purposes, or when requested by organizations authorized by the customer.

Entities receiving information for the purpose of benefits determination, public agencies receiving information, or any other organization with legitimate right to information will maintain information in confidence with the same rigor and be subject to the same penalties as C & R Medical.

Information technology will be used for transmission, storage, or data management, and assure the protection of the individuals privacy.

 
I have been given a copy of the “Customer’s Bill of Right’s”. I have read and understand the document.

CMS Supplier Standards:

CMS Medicare DMEPOS Supplier Standards

All Medicare DMEPOS supplier must be in compliance with these Supplier Standards in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. pt. 424, sec 424.57(c) and went into effect December 11, 2000.

A supplier must disclose these standards to all customers/patients who are Medicare beneficiaries (standard 16). A shortened version has been created to help suppliers comply with this requirement.

1. Operates its business and furnishes Medicare-covered items in compliance with all applicable Federal and State licensure and regulatory requirements.

2. Has not made, or caused to be made, any false statement or misrepresentation of a material fact on its application for billing privileges. (The supplier must provide complete and accurate information in response to questions on its application for billing privileges. The supplier must report to CMS any changes in information supplied on the application within 30 days of the change.).

3. Must have the application for billing privileges signed by an individual whose signature binds a supplier.

4. Fills orders, fabricates, or fits items from its own inventory or by contracting with other companies for the purchase of items necessary to fill the order. If it does, it must provide, upon request, copies of contracts or other documentation showing compliance with this standard. 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 Government Executive Branch procurement or non-procurement program or activity.

5. Advises beneficiaries that they may either rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental durable medical equipment, as defined in Sec. 414.220(a) of this subchapter. (The supplier must provide, upon request, documentation that it has provided beneficiaries with this information, in the form of copies of letters, logs, or signed notices.).

6. Honors all warranties expressed and implied under applicable State law. A supplier must not charge the beneficiary or the Medicare program for the repair or replacement of Medicare covered items or for services covered under warranty. This standard applies to all purchased and rented items, including capped rental items, as described in Sec. 414.229 of this subchapter. The supplier must provide, upon request, documentation that it has provided beneficiaries with information about Medicare covered items covered under warranty, in the form of copies of letters, logs, or signed notices.

7. Maintains a physical facility on an appropriate site. The physical facility must contain space for storing business records including the supplier's delivery, maintenance, and beneficiary communication records. For purposes of this standard, a post office box or commercial mailbox is not considered a physical facility. In the case of a multi-site supplier, records may be maintained at a centralized location.

8. Permits CMS, or its agents to conduct on-site inspections to ascertain supplier compliance with the requirements of this section. The supplier location must be accessible during reasonable business hours to beneficiaries and to CMS, and must maintain a visible sign and posted hours of operation.

9. Maintains a primary business telephone listed under the name of the business locally or toll-free for beneficiaries. The supplier must furnish information to beneficiaries at the time of delivery of items on how the beneficiary can contact the supplier by telephone. The exclusive use of a beeper number, answering service, pager, facsimile machine, car phone, or an answering machine may not be used as the primary business telephone for purposes of this regulation.

10. Has a comprehensive liability insurance policy 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. In the case of a supplier that manufactures its own items, this insurance must also cover product liability and completed operations. Failure to maintain required insurance at all times will result in revocation of the supplier's billing privileges retroactive to the date the insurance lapsed.

11. Must agree not to contact a beneficiary by telephone when supplying a Medicare-covered item unless one of the following applies:

a. The individual has given written permission to the supplier to contact them by telephone concerning the furnishing of a Medicare- covered item that is to be rented or purchased.

b. The supplier has furnished a Medicare-covered item to the individual and the supplier is contacting the individual to coordinate the delivery of the item.

c. If the contact concerns the furnishing of a Medicare-covered item other than a covered item already furnished to the individual, the supplier has furnished at least one covered item to the individual during the 15-month period preceding the date on which the supplier makes such contact.

12. Must be responsible for the delivery of Medicare covered items to beneficiaries and maintain proof of delivery. (The supplier must document that it or another qualified party has at an appropriate time, provided beneficiaries with necessary information and instructions on how to use Medicare-covered items safely and effectively).

13. Must answer questions and respond to complaints a beneficiary has about the Medicare-covered item that was sold or rented. A supplier must refer beneficiaries with Medicare questions to the appropriate carrier. A supplier must maintain documentation of contacts with beneficiaries regarding complaints or questions.

14. Must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries. The item must function as required and intended after being repaired or replaced.

15. Must accept returns from beneficiaries 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).

16. Must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.

17. Must comply with the disclosure provisions in Sec. 420.206 of this subchapter.

18. Must not convey or reassign a supplier number.

19. Must have a complaint resolution protocol to address beneficiary complaints that relate to supplier standards in paragraph (c) of this section and keep written complaints, related correspondence and any notes of actions taken in response to written and oral complaints. Failure to maintain such information may be considered evidence that supplier standards have not been met. (This information must be kept at its physical facility and made available to HCFA, upon request.).

20. Must maintain the following information on all written and oral beneficiary complaints, including telephone complaints, it receives:

(i) The name, address, telephone number, and health insurance claim number of the beneficiary.

(ii) A summary of the complaint; the date it was received; the name of the person receiving the complaint, and a summary of actions taken to resolve the complaint.

(iii) If an investigation was not conducted, the name of the person making the decision and the reason for the decision.

21. Provides to CMS upon request, any information required by the Medicare statute and implementing regulations.

DMEPOS Supplier Standards:

This letter is to inform you about your HCFA Medicare DMEPOS Supplier Standards. Your medical supply company (C & R Medical) must be in compliance with the HIPPA laws and satisfy our customers.

If you have any questions or concerns about the HCFA Medicare DMEPOS supplier standards, please give us a call at (817) 590-8166, or toll-free at 1-866-676-3928.

Signature: Date:

Protocol for Resolving Complaints from Beneficiaries:

The patient has the right to freely voice grievances and recommend changes in care or services without fear of reprisal or unreasonable interruption of services. Service, equipment, and billing complaints will be communicated to management and upper management. These complaints will be documented in the Beneficiaries Complaint Log, and completed forms will include the patient’s name, address, telephone number, health insurance claim number, a summary of the complaint, the date it was receive, the name of the person receiving the complaint, and a summary of actions taken to resolve the complaint.

All complaints will be handled in a professional manner. All logged complaints will be investigated, acted upon, and responded to in writing or by telephone by a manager within a reasonable amount of time after the receipt of the complaint. If there is no satisfactory resolution of the complaint, the next level of management will be notified progressively and up to the CEO of the company.

The patient will be informed of this complaint resolution protocol at the time of set-up of service.

Beneficiary's Signature:
Date:

Change of Supplier:

To Whom It May Concern:

I, , will no longer need as my Durable Medical Equipment (DME) supplier. The last date which I received services from was .
I request C & R Medical to be my DME supplier for my medical supply needs.

 
Effective Date:
Medicaid/Medicare #:
Print Name:
Signature:

Authorization/Assignment of Benefits:

I authorize my doctor’s, current medical supplier’s, and hospital’s, patient records department to release my medical records or other information necessary to process medical claims submitted by C & R Medical on my behalf. I also request payment of medical benefits to the Durable Medical Equipment supplier, C & R Medical, for services rendered upon my behalf or to the party who accepts assignment. My current medical equipment supplier is: .

I authorize payment of medical benefits to the durable medical equipment supplier, C & R Medical, for the services rendered upon my behalf.

A copy of the HCFA Medicare 25 Supplier Standards has been provided to me.

Patient/Beneficiary Name:
DOB:
Address:
City: State: Zip:
Daytime Telephone:
Doctor's Name:

What type of medical supply products do you use? Please list all supplies by quantity and type and provide daily usage.



Signature:
Patient/Beneficiary/Responsible Party
If signing on behalf of patient, please state your relationship: