CUSTOMER

HANDBOOK

Phone:  218-326-2212     877-326-2212

Fax:   218-326-0232

1001 S Pokegama Ave Ste A 

Grand Rapids, MN  55744

                                        Visit us at www.custommedicalequipment.com

 The Mission of Custom Medical Equipment is: “To provide the highest quality of medical equipment and    services to our customers in Northern Minnesota.”

* In accordance  with American with Disabilities (ADA), Custom Medical Equipment provides equal access to our store entrance, office, exam room, bathroom, and equipment

 * All Custom Medical Equipment employee's complete Cultural competency training yearly to help us to better understand your background, values, and beliefs to adapt services to meet your social, cultural and language needs. 

 CUSTOM MEDICAL EQUIPMENT, LLC, POLICIES

• Inserted in your handbook is a copy of Notice of Privacy Practices.  
• Hours:                                                                                                    

      8:00 a.m. - 4:30 p.m. Monday - Friday and Saturday by appointment.

      1001 S Pokegama Ave Ste A, Grand Rapids, MN, 55744

(218) 326-22121-877-326-2212Fax (218) 326-0232

• After Hour Service:

     In the event of an after hour equipment emergency or delivery please                                              

     contact our after hour on call emergency number at (218) 259-5657.

• Return Policy:

      Cash refunds greater than $25 will be mailed to customers within 14 days. All      

       returns must be accompanied by the original sales slip.

      Stock Items:

      Items can be returned within 5 days of purchase. Products must be                 

       in their original package and unused. 

      Non-Returnable Items:

       *Special Orders *Non-Stock Items  *Fabricated Items  *Used or Opened Items

       *Bath Products

• Rental Policy:

     Rental charges are subject to minimum rental periods. Rentals are                

      billed on a monthly cycle and are not prorated. Patient agrees to care for, use as      

      instructed and return rental equipment in good, clean condition (normal wear 

      expected) at the end of the rental period. Patient responsible for loss and         

      damages beyond normal wear. Custom Medical Equipment shall not insure or    

      be responsible to patient or any other party for personal injury or property          

      damage related to any equipment purchased or rented.

• Credit Policy:

     Custom Medical Equipment, LLC, will file insurance claims.                       

     (Visa/MasterCard/Discovery accepted.) Insurance co-payments and      

     self-pay portions are due and payable at the time of order.

• Warranty:

     Warranties are extended by the manufacturer, NOT Custom Medical   

      Equipment, LLC. Warranties cover parts only and do not cover       

      labor.

We are a DME company located in Grand Rapids, MN. Travis Czerny, our ATP, is certified to fit patients to custom wheelchairs. Travis has 17 years experience in the durable medical equipment business. We cover a two hour radius of Grand Rapids. We provide in home evaluations and service. We can help with providing the following equipment:

• Beds                                                     
• Scooters
• Ceiling Lifts
• Vehicle Lifts
• Bathroom Aides
• Manual Wheelchairs
• Power Wheelchairs
• Custom Seating Systems
• Supplies
• Lift Chairs
• ADL equipment
• Hoyer Lifts
• Standers
• Walking Aides
• In Home Evaluations and Service   

The Mission of Custom Medical Equipment is: “To provide the highest quality of medical equipment and services to our customers in Northern Minnesota.”

CUSTOM MEDICAL EQUIPMENT, LLC

Patient Bill of Rights

Rights and Responsibilities

As a patient of Custom Medical Equipment, you have the right to, which includes but is not limited to, the following:

1.  Be given information about your rights for receiving DME services.

2.  Receive a timely response from Custom Medical Equipment regarding your request for DME services.

3.  Be given information about Custom Medical Equipment policies, procedures and charges for services.

4.  Choose your DME providers.

5.  Be given appropriate and professional quality DME services without discrimination against your race, creed, color, religion, sex, national origin, sexual orientation, handicap, or age.

6.  Be treated with courtesy and respect by all who provide DME services to you.

7.  Be free from physical and mental abuse and/or neglect.

8. Be given proper identification by name and title of everyone who provides DME services to you.
9. Be given the necessary information regarding treatment and choices concerning rental or purchase options for durable medical equipment, so you will be able to give informed consent for your service prior to the start of any service.
10. Be given complete and current information concerning your diagnosis, treatment, alternatives, risks and prognosis as required by your physician's legal duty to disclose in terms and language you can reasonably be expected to understand.
11. A plan of service that will be developed to meet your unique service needs.
12. Participate in the development of your plan of care/service.
13. Be given an assessment and update of your developed plan of care/service.
14. Be given data privacy and confidentiality.
15. Review your clinical record at your request.
16. Be given information regarding anticipated transfer of your DME service to another DME facility and/or termination of DME service to you.
17. Voice grievance with and/or suggest a change in DME services and/or staff without being threatened, restrained and discriminated against.
18. Refuse treatment within the confines of the law.
19. Be given information concerning the consequences of refusing treatment.
20. Have an advance directive for medical care, such as a living will or the designation of a surrogate decision maker, respected to the extent provided by the law.
21. Participate in the consideration of ethical issues that arise in your care.

Patient Responsibilities

Rights alone do not guarantee the achievement of our objectives to provide quality care. Each patient has a responsibility to:

1. Follow the treatment plan prescribed. It is your responsibility to advise the     

                people treating you whether or not you think you can, or want to, follow a 

                certain treatment plan; 

2. Report changes in your health to the people treating you; 

3. Be honest and direct with the people caring for you. Tell them exactly how you           

          feel about the things that are happening to you; 

4. When you want to know, please ask. If you have something to say, please speak       

           up.

5. Patient should notify Custom Medical Equipment promptly if their address,   

          phone or physician changes.

6. Notify Custom Medical Equipment of equipment failures or discontinuation of    

          Use.

CUSTOM MEDICAL EQUIPMENT

1001 S Pokegama Ave Ste A

Grand Rapids, MN 55744

218-326-2212

1-877-326-2212

Thank you for choosing us as your provider of home medical equipment andsupplies! Each of our staff members is specially selected and highly trained inproviding the best possible service.

A few important points about us:

• Please call us a minimum of 24 hours in advance if you have any medical equipment emergencies. While we are available 24 hours a day by telephone, if you have an equipment emergency problem, we may take up to twohours to arrive at your residence during non-business hours. It isalways better to plan ahead!
• In the case of a disaster or extremely severe weather, which results in along-term (more than 4 hours) power outage, we will attempt to contact you toassess your needs & our ability to serve you safely. Remember, you areultimately responsible for residing in a location that has adequate electricalservice. Please develop a plan now to move, taking our equipment with you,to a location that has adequate electrical service. We suggest you alwayshave a Portable, battery-powered radio available to monitor the weather & aflashlight, both with fresh batteries.
• We always wear name tags for your safety.
• If you have a medical emergency, we suggest you call 911. Do not call us,our staff does not provide CPR. Should you have Advance Directives or a DoNot Resuscitate (DNR) order, please provide us with a copy & a copy ofthose orders should be available at all times for emergency personnel.
• Please call us at anytime between 8 am and 4:30 pm weekdays if you have aquestion or comment about your bill or any of our services. Our staff will behappy to serve you. 

Thank you, 

CME Management

                                                                                   Check for Safety

A Home Fall Prevention Checklist 

Each year, thousands of older Americans fall at home. Many of them are seriously injured, and some are disabled. In 2002, more than 12,800 people over age 65 died and 1.6 million were treated in emergency departments because of falls. Falls are often due to hazards that are easy to overlook but easy to fix. This checklist will help you find and fix those hazards in your home.

The checklist asks about hazards found in each room of your home. For each hazard, the checklist tells you how to fix the problem. At the end of the checklist, you’ll find other tips for preventing falls.

• FLOORS: Look at the floor in each room.

Q: When you walk through a room, do you have to walk around furniture?

• Ask someone to move furniture so your path is clear.

Q: Do you have throw rugs on the floor?

• Remove the rugs or use double sided tape or a non-slip backing so the rugs won’t slip.

Q: Are there papers, books, towels, shoes, magazines, boxes, blankets, or other objects on the floor?

• Pick up things that are on the floor. Always keep objects off the floor.

Q: Do you have to walk over or around wires or cords (like lamp, telephone, or extension cords)?

• Coil or tape cords and wires next to the wall so you can’t trip over them. If needed, have an electrician put in another outlet.

• STAIRS AND STEPS: Look at the stairs you use both inside and outside your home.

Q: Are there papers, shoes, books, or other objects on the stairs?

• Pick up things on the stairs. Always keep objects on the stairs?

Pick up things on the stairs. Always keep objects off stairs.

Q: Are some steps broken or uneven?

• Fix loose or uneven steps.

Q: Are you missing a light cover over the stairway?

• Have an electrician put in an overhead light at the top and bottom of the stairs.

Q: Do you have only one light switch for your stairs (only at the top or at the bottom of the stairs)?

• Have an electrician put in a light switch at the top and bottom of the stairs. You can get light switches that glow.

Q: Has the stairway light bulb burned out?

• Have a friend or family member change the light bulb.

Q: Is the carpet on the steps loose or torn?

• Make sure the carpet is firmly attached to every step, or remove the carpet and attach non-slip rubber treads to the stairs.

Q: Are the handrails loose or broken? Is there a handrail on only one side of the stairs?

• Fix loose handrails or put in new ones. Make sure handrails are on both sides of the stairs and are as long as the stairs.

• KITCHEN: Look at your kitchen and eating area.

Q: Are the things you use often on high shelves?

• Move items in your cabinets. Keep things you use often on the lower shelves (about waist level).

Q: Is your step stool unsteady?

• Get one with a bar to hold on to. Never use a chair as a step stool.

• BATHROOMS: Look at all your bathrooms.

Q: Is the tub or shower floor slippery?

• Put a non-slip rubber mat or self-stick strips on the floor of the tub or shower.

Q: Do you need some support when you get in and out of the tub or up from the toilet?

• Have a carpenter put grab bars inside the tub and next to the toilet.

• BEDROOMS: Look at all your bedrooms.

Q: Is the light near the bed hard to reach?

• Place a lamp close to the bed where it’s easy to reach.

Q: Is the path from your bed to the bathroom dark?

• Put in a night-light so you can see where you’re walking. Some night-lights go on by themselves after dark.

• Think about wearing an alarm device that will bring help in case you fall.

When using any home medical equipment (walkers, canes, wheelchairs, etc.) know how to use it properly. If you don’t, ask! Also keep in mind that as you begin to use your new equipment, it will take time to adjust and you may need to be extra careful during this time to avoid stumbles or falls.

• Home Fire Safety Tips
• Heat Your home safely.
• Arrange for regular cleaning and maintenance of heating systems and chimneys.
• Install a carbon monoxide detector.
• Keep potable heaters at least three feet from people and objects.
• Avoid Smoking
• It’s best not to smoke, but if a member of your household does, follow these rules:
• Never smoke in bed.
• Never smoke when oxygen equipment is in use.
• Never leave smoking materials unattended.
• Never throw out smoking material that are still hot or burning.
• Install smoke detectors and plan a fire escape.
• Have a smoke detector on every level of your home.
• Test smoke detectors once a month.
• Plan at least two ways out of the home from each room.
• Pick a meeting place outside the home.
• Practice your fire escape plan at least twice a year.
• Take Care with Electricity.
• Throw out or repair damaged or frayed electrical cords.
• Never overload electrical outlets.
• Keep electrical appliances away from sink, tub and shower areas. 

• Emergency Preparedness
• Be prepared for power outages, major storms and other emergencies.
• List emergency numbers by the phone.
• Include fire, police, ambulance and utility company.
• Register with your local utility.
• Patients with oxygen systems or other electrically powered medical equipment should register as (priority) customers with their local utility company. Also register with you fire department.
• Keep emergency supplies on hand.
• Flashlights
• Portable radio
• Back up power supply for any device that would create a life-threatening situation if it stopped working.
• Canned foods and bottle water
• Medicine and medical supplies

 Keep the listing where it is easily accessible.

1.  Emergency 911, if available in your area

2.  Local Law Enforcement______________________________________

3.  Local Hospital or Clinic______________________________________

4.  Local Ambulance___________________________________________

5.  Power Company____________________________________________

6.  County Sheriff Department___________________________________

7.  Emergency Broadcast Radio Station___________________________

_____________________________________________________________

• Tips for Avoiding Infection

Practice good personal hygiene.

Patients and caregivers should wash hands often.

Do laundry regularly.

Change soiled linens and bed clothes promptly.

Contact your health provider for information on disposing of contaminated waste materials such as soiled wound dressings or used syringes and needles.

• Medical Equipment Safety Statement

The medical equipment Custom Medical Equipment has provided for your benefit and comfort should be maintained and used properly. The following are some suggestions:

1. Do not use extension cords with you medical device.

2. Never plug a medical device into a multiple electrical plug.

3. Follow all directions exactly. 

4. Do not allow children or untrained individuals to operate your medical device(s) or equipment.

5. If Custom Medical Equipment, LLC, has installed a temporary adaptor to   

    provide immediate service, it is the customer’s responsibility to provide a 

    properly grounded outlet as soon as possible.

6. Never keep medical equipment stored outdoors.

7. Wheel locks on wheelchairs must be locked before transferring in or out of 

    wheelchairs.

8. Use grounded outlets to avoid overloading electrical circuits.

9. Use the home prevention fall checklist prior to equipment use.

10. Read all manuals and customer handbook before using your medical device or equipment.

11. Periodically evaluate your skin for red or sore areas. Notify your physician and Custom Medical Equipment, LLC. We will evaluate and determine if it is related to you medical device or equipment.

12. Secure all medical equipment and devices when transporting in your vehicle.      

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU

MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO

THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures

Treatment. Your health information may be used by staff members or disclosed

to other health care professionals for the purpose of evaluating your

health, diagnosing medical conditions, and providing treatment. For example,

results of laboratory tests and procedures will be available in your medical

record to all health professionals who may provide treatment or who may

be consulted by staff members.

Payment. Your health information may be used to seek payment from your

health plan, from other sources of coverage such as an automobile insurer, or

from credit card companies that you may use to pay for services. For example,

your health plan may request and receive information on dates of service,

the services provided, and the medical condition being treated.

Health care operations. Your health information may be used as necessary

to support the day-to-day activities and management of Custom Medical Equipment.

For example, information on the services you received may be used to support

budgeting and financial reporting, and activities to evaluate and promote

quality.

Law enforcement. Your health information may be disclosed to law enforcement

agencies to support government audits and inspections, to facilitate

law-enforcement investigations, and to comply with government-mandated

reporting.

Public health reporting. Your health information may be disclosed to public

health agencies as required by law. For example, we are required to report

certain communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization. Disclosure of your

health information or its use for any purpose other than those listed above

requires your specific written authorization. If you change your mind after

authorizing a use or disclosure of your information you may submit a written

revocation of the authorization. However, your decision to revoke the authorization

will not affect or undo any use or disclosure of information that

occurred before you notified us of your decision to revoke your authorization.

Additional Uses of Information

Appointment reminders. Your health information will be used by our staff

to send you appointment reminders.

Information about treatments. Your health information may be used to

send you information that you may find interesting on the treatment and

management of your medical condition. We may also send you information

describing other health-related products and services that we believe may

interest you.

Individual Rights

You have certain rights under the federal privacy standards. These include:

◆The right to request restrictions on the use and disclosure of your

protected health information

◆The right to receive confidential communications concerning your

medical condition and treatment

◆The right to inspect and copy your protected health information

◆The right to amend or submit corrections to your protected health

information

◆The right to receive an accounting of how and to whom your protected

health information has been disclosed

◆The right to receive a printed copy of this notice

Custom Medical Equipment Duties

We are required by law to maintain the privacy of your protected health

information and to provide you with this “Notice of Privacy Practices.”

We also are required to abide by the privacy policies and practices that are

outlined in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy

policies and practices. These changes in our policies and practices may be

required by changes in federal and state laws and regulations. Upon request,

we will provide you with the most recently revised notice on any office visit.

The revised policies and practices will be applied to all protected health

information we maintain.

Requests to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we

maintain. As permitted by federal regulation, we require that requests to

inspect or copy protected health information be submitted in writing. You

may obtain a form to request access to your records by contacting

our Compliance Officer, Josephine Czerny. Your request will be reviewed

and will generally be approved unless there are legal or medical reasons to

deny the request.

Complaints

If you would like to submit a comment or complaint about our privacy practices,

you can do so by sending a letter outlining your concerns to:

Compliance Officer

Josephine Czerny

1001 S Pokegama Ave Ste A

Grand Rapids, MN 55744

If you believe that your privacy rights have been violated, you should call the

matter to our attention by sending a letter describing the cause of your concern

to the same address.

You will not be penalized or otherwise retaliated against for filing a complaint.

Contact Person

The name and address of the person you may contact for further information

concerning our privacy practices is:

Compliance Officer

Josephine Czerny

1001 S Pokegama Ave Ste A

Grand Rapids, MN 55744

Effective Date:

This notice is effective on or after October 1, 2008

                                                                                           STORE LOCATION

TELEPHONE NUMBERS AND HOURS

Grand Rapids

1001 S Pokegama Ave Ste A, Grand Rapids, MN, 55744

(218) 326-22121-877-326-2212Fax (218) 326-0232

Hours: 8:00 a.m. - 4:30 p.m. Monday - Friday and Saturday by appointment.

     CUSTOM MEDICAL EQUIPMENT, LLC  COMPLAINT/GRIEVANCE

Contact Travis Czerny (Manager), at 218-326-2212 or email at: travisczerny@custommedicalequipment.com to file a complaint/grievance.  Within five calendar days of receiving a beneficiary‘s complaint, Custom Medical Equipment shall notify the beneficiary using either oral, telephone, e-mail, fax, or letter format, that it has received the complaint that it is investigating.  Within 14 calendar days, Custom Medical Equipment shall provide written notification to the beneficiary of the results of it’s investigation and response.

 The products and/or services provided to you by Custom Medical Equipment 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 obtained at http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards.



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. 

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. A supplier must have an authorized individual (whose signature is binding) sign the enrollment application for billing privileges. 

4. A supplier must fill orders from its own inventory, or contract with other companies for the purchase of items necessary to fill orders. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or any other Federal procurement or non-procurement 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 and must maintain a visible sign with posted hours of operation. The location must be 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 on-site inspections to ascertain the supplier’s compliance with these standards. 

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 is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition see 42 CFR § 424.57 (c) (11). 

12. A supplier is responsible for delivery of and must instruct beneficiaries on the use of Medicare covered items, and maintain proof of delivery and beneficiary instruction. 

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 cost either directly, or through a service contract with another company, any Medicare-covered 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 standards to each beneficiary it supplies a Medicare-covered item. 

17. A supplier must disclose 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 regulations. 

22. All suppliers must be accredited by a CMS-approved 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 for those specific products and services (except for certain exempt pharmaceuticals). 

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. A supplier must meet the surety bond requirements specified in 42 CFR § 424.57 (d). 

27. A supplier must obtain oxygen from a state-licensed oxygen supplier. 

28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 CFR § 424.516(f). 

29. A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers. 

30. A supplier must remain open to the public for a minimum of 30 hours per week except physicians (as defined in section 1848(j) (3) of the Act) or physical and occupational therapists or a DMEPOS supplier working with custom made orthotics and prosthetics.