Matriarch Customer Agreement and Information Guide
- Customer Agreement
- Hours of Availability
- Safety Precautions
- Emergency or Natural Disaster
- Customer Suggestions or Complaints
- Customer Bill of Rights and Responsibilities
- HIPAA Notice of Information/Privacy Practices
- DME Supplier Standards
- Community Resources
- Upgrade Policy
SECTION ONE: Customer Agreement
- I understand that Matriarch Women’s Health Supply (“Matriarch”) is independently owned and operated and is not in any way associated with a hospital, medical practice or any other clinic.
- I request payment under my medical insurance, Medicaid, or Medicare to be made directly to Matriarch. In the event my medical insurance does not make payment because they paid a breast pump claim from a different order I knowingly made, I agree to pay Matriarch the usual and customary amount/ price for this equipment up to a maximum of $325.
- I authorize any provider of my medical information to release any information necessary to determine services, benefits and payment on my behalf. I permit a copy of this authorization to be used in place of the original. I permit the review of my record by accrediting and licensing agents and/or for the purpose of quality control.
- I certify that the information provided by me and applying for payment under Title XVIII (Medicare) of the Social Security Act or any other insurance benefits is true and correct.
- I certify that I have been provided the Hours of Availability, Instructions for Set-Up of HME, Safety Precautions, Emergency or Natural Disaster Information, Customer Complaint Policy, Customer Bill of Rights & Responsibilities, HIPAA Privacy Notice, DME Supplier Standards and Community Resources (view Sections 3 through 11).
- I acknowledge that I have been trained and/or will be trained on the use, cleaning and maintenance of all products I receive from Matriarch.
- I agree that Matriarch may contact me in the future via text, telephone, email, or regular mail.
- Owner’s manual with warranty information has been or will be provided to me for all durable medical equipment.
- I certify that I have read this agreement and any attachments, and agree to its content.
SECTION TWO: Hours of Availability
Matriarch is available to serve our customers Monday through Friday from 9:00 am to 5:00 pm. Matriarch maintains emergency, on-call service for any calls outside normal business hours. To contact us during and after business hours, please call 210-591-1818.
SECTION THREE: Safety Precautions
Please make sure you read all instructions before using equipment.
SECTION FOUR: Emergency or Natural Disaster
If you are in need of emergency medical treatment during a natural disaster or other medical emergency, contact 911.
SECTION FIVE: Client Suggestions or Complaints
We value your suggestions and we will work hard to resolve any complaints. If you have a suggestion or a complaint, please call Matriarch at 210-591-1818 and your call will be handled in a professional and confidential manner. You will be asked to provide your name, address, telephone number, health insurance number, if applicable, and a summary of the complaint. All logged complaints are received by management within 1 business day and the client will be contacted by management within 2 business days. You also have the right to register a complaint with the company’s accrediting body, American Board Certification (“ABC”) at https://www.abcop.org.
SECTION SIX: Client Bill of Rights and Responsibilities
Matriarch recognizes you have rights as a client receiving medical products or services. In return, there are responsibilities for certain behavior on the part of the client. We believe that all clients receiving products or services from Matriarch should be informed of their rights and responsibilities. The full text of Client Rights and Responsibilities can be found at matriarchwomenshealthsupply.com/responsibilities. Upon request we will furnish you a written copy of this document.
SECTION SEVEN: HIPAA Notice of Information/Privacy Practices
Matriarch is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time. The purpose of this notice is to inform you, the client, how your personal health information is used and/or disclosed by Matriarch as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We want you to be fully aware of what we do with your information so that you can provide us with your consent in order for us to treat your health care needs, receive payment for services rendered, and allow administrative and other types of health care operations to happen, which are part of normal business activities of Matriarch. The full text of the HIPAA/Privacy Notice can be found at matriarchwomenshealthsupply.com/privacy. Upon request we will furnish you a written copy of this document.
SECTION EIGHT: DME Supplier Standards
The products and/or services provided to you by Matriarch Women’s Health Supply 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 found at matriarchwomenshealthsupply.com/supplierstandards. Upon request we will furnish you a written copy of this document.
SECTION NINE: Community Resources
Breastfeeding – Visit http://latchedsupport.com/
Cystic Fibrosis – Visit cff.org or call (800) FIGHT CF
American Red Cross – Visit redcross.org or call (800) 733-2767
Asthma and Allergy Foundation of America – Visit aafa.org or call (800) 727-8462
SECTION TEN: Upgrade Policy
NOTICE TO MEMBER: Your health care benefit plan may prohibit participating health organizations such as Matriarch from charging members such as you for any medical equipment offered as an upgrade that are deemed not medically necessary or non-covered for other reasons, unless the Member (such as you) specifically requests such service or product and agrees to be financially responsible for it. By acknowledging in your registration with Matriarch that you have reviewed this “Upgrade Policy” you are agreeing to the following:
“I understand and agree that I am financially responsible for the difference between my health care benefit plans reimbursement rate for the “Basic” medical equipment and the Providers usual and customary charges for the “Deluxe” upgraded medical equipment I have selected. I have been offered the “Basic” model and understand my insurer may cover 100% of the costs on the “Basic” model, but prefer the different features and/or design of the “Deluxe” upgraded model.
I understand my out of pocket payment for the “Deluxe” upgraded model will not show on my Explanation of Benefits as my financial responsibility nor will my health care benefit plan reimburse me for this expense.”