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We must have the following signed, dated, original documents in our possession before you place an order if you are a Medicare Beneficiary.
1. A copy of your Medicare Card.
3. A signed "Admission of Informed Consent" form. This form confirms that you understand that you are agreeing to receive services provided by Austin Medical Products, Inc., that you understand and have received a written decription of services, that you may be required to pay for your services in part or in full, that you authorize us to release medical and other necessary information to Medicare for the claims we submit for you, that Austin Medical does not accept assignment and that you have received a copy of our Privacy Practices, Patient Bill of Rights, DEMPOS Supplier Standards, a Medical Release form and written instructions pertaining to the proper use of the AMPatch.
2. A prescription from your physician stating your name, a description of the item(s) being prescribed (i.e. AMPatch stoma covers, catheters, lubricant, skin prep., etc.), the number per usage, the number per day, the length of need, the physician's signature and signature date. This prescription will serve as your physician's order for Medicare.
3. Copies of Progress Notes from your medical chart. If you require more stoma covers and/or other supplies than what Medicare routinely covers (see below), we will require copies of Progress Notes from your medical chart which document your medical condition, the medical necessity for the stoma covers (and/or other supplies) and the quantity needed per day. The Progress Notes must rationalize the need for more than the quantity of supplies normally allowed by Medicare. If you require more than the usual monthly allowance provided by Medicare (see below), Progress Notes (from your medical chart, written by your Healthcare Provider) are the only documentation that Medicare will accept. Without this documentation, your claims will likely be denied as not medically necessary. To make this process easier, you will find a link at the top of the page titled "Record Release". This will allow us to contact your physician directly and obtain the records needed. Please print the page, fill in the information and send it to:
Austin Medical Products, Inc.
P.O. Box 1830
Conway, NH 03818
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