Patient Consent

By providing my contact information, I authorize Midwest Compression LLC to contact me regarding my order, account, or other services or products provided by Midwest Compression LLC. A detailed description of my rights is in the Notice of Privacy Practices. Midwest Compression LLC will never disclose my personal information to unrelated third parties. The full Notice of Privacy Practices is available on our website.

Family / legal guardian / emergency contacts

Consent for the use and disclosure of protected health information (HIPAA)

• I understand that Midwest Compression LLC originates, collects and maintains paper and/or electronic records describing my Protected Health Information (PHI), such as health history, diagnosis, symptoms and test results. I consent to the use and disclosure of my PHI by Midwest Compression LLC, its staff and its business associates for treatment, payment and healthcare operations.
• I acknowledge that I have received, or have been offered, a copy of the Midwest Compression LLC Notice of Privacy Practices (HIPAA). It is included in the Patient Information Booklet and is available at midwestcompression.com/new-patient-forms.
• I understand I have the right to request restrictions on, or revoke in writing, any use and/or disclosure of my PHI by Midwest Compression LLC. I can contact customer service at 800-883-1549 with questions. This authorization is effective for five (5) years unless otherwise provided by law.
• I authorize my healthcare providers to release to Midwest Compression LLC and to my insurance company(ies) all PHI necessary to complete my equipment order. I authorize Midwest Compression LLC to release to Medicare (CMS), Medicaid, the Social Security Administration or any other insurer any information needed for this or a related claim.

Assignment of benefits & financial responsibility

I assign payment of medical benefits to Midwest Compression LLC and direct any insurance (payer) to make payment on my behalf directly to Midwest Compression LLC for medical equipment provided. Any costs not covered by my insurance are my responsibility. If for any reason insurance will not complete the purchase of the device (including a change of insurance), I must 1) pay the remaining cost out of pocket or 2) return the device and pay my assigned balance. If my insurance makes payment directly to me for the medical equipment, I am responsible for making sure payment in full is made promptly to Midwest Compression LLC.

Release & financial responsibility

I release Midwest Compression LLC from any and all claims for injury arising from the equipment I receive, to the extent permitted by law. If my insurance, Medicare or Medicaid does not pay for the equipment listed on my delivery ticket, I will be fully responsible for paying Midwest Compression LLC for that equipment.

Acknowledgment of receipt

Please open and read each document below (each opens in a new window, and you can save or print it). By checking the box, I confirm I have received, or have been offered, the following:

• My Rights and Responsibilities
• Notice of Privacy Practices (HIPAA)
• Medicare DMEPOS Supplier Standards
• Warranty and Return Policy
• Complaint resolution and fraud reporting
• Emergency preparedness information and instructions for the safe and proper use, cleaning and care of my equipment – in the Patient Information Booklet

All of these are in the complete Patient Information Booklet. If you would like a printed copy mailed to you, call 800-883-1549.

Warranty & returns

Warranties, returns and exchanges follow the Midwest Compression LLC Warranty & Return Policy, which I will sign separately. Compression garments and supplies that have been opened, worn or laundered cannot be returned. For equipment rented through insurance, the patient is responsible for outstanding financial obligations for the period in which they had the product.

Patient signature