CONTRACT AGREEMENT

Individuals signing for the customer represent that they are duly authorized to do so and that once signed, this agreement becomes binding upon the patient. The patient agrees to pay for the replacement cost of any equipment damaged, destroyed, or lost due to misuse, abuse, or neglect. The customer agrees not to modify the rental equipment without the prior written consent of Kern Medical Supply, LLC. The customer agrees that Title to the rental equipment and all parts shall remain with Kern Medical Supply, LLC at all times, unless equipment is purchased and paid for in full. Kern Medical Supply, LLC fully warrants used equipment purchased for a minimum of 30 days from the date of purchase. The patient agrees that if they or their respective insurance company(s) fail to make payment within 30 days after it becomes due, Kern Medical Supply, LLC shall have their rights to reacquire all equipment. Delinquent accounts are subject to $15 late fees. Also, to pay interest 1.5% per month on any delinquent balance, and in the event that a delinquent account is placed in the hands of a licensed collector, or attorney, to pay in addition to the amount of said account an equal to 10% thereof to cover collection costs. It is understood that the term for all rentals shall repeat on the monthly anniversary date of the original rental. Lessor shall not be held harm from any damages which might be caused by equipment or any damages which might be caused by failure or breakdown of the equipment.

IF ANY OF THE EQUIPMENT ON THIS ORDER IS BEING PURCHASED, THE FOLLOWING PARAGRAPH IS APPLICABLE.

It is understood that by entering into this installment sales agreement that Kern Medical Supply, LLC retains title to the equipment until all installment and/or service charges are paid in full. The patient’s failure to pay installments in accordance with the terms of this agreement will result in termination of agreement and Kern Medical Supply, LLC can reacquire equipment. The patient may voluntarily terminate the agreement by returning equipment, however, all installment payments made will be considered rental payments, and no refunds or adjustments will be made. Kern Medical Supply, LLC will assume responsibility for maintenance of the equipment during the installment period and reserves the right to repair or replace equipment at its sole discretion. Once the final installment and all service charges are paid in full, the Title of the equipment will be passed to the customer and the customer will be responsible for all repair and maintenance charges. (Some manufacturer warranties may exceed those mentioned in this agreement.)

As a customer, an immediate family member of a customer, or a power of attorney for a customer of Kern Medical Supply, LLC you have some basic rights and responsibilities:

RIGHTS

1. To be informed of your rights and responsibilities before the initiation of care.
2. To be treated with dignity, respect, and consideration by qualified staff.
3. Exercise your rights as a patient or have your guardian exercise your rights.
4. Have your personal property treated with respect, dignity, and privacy.
5. To have equipment repaired if it is on rental status with Kern Medical Supply, LLC.
6. To be informed in advance of the extent to which payment may be expected from a third-party payer and what costs you will be responsible for and to be advised no later than 30 days after Kern Medical Supply, LLC becomes aware.
7. To return SALE items within 30 days of sale if in unopened original manufacturer packaging. A minimum of one-month rental may be deducted where applicable. No merchandise will be accepted for return if worn next to the skin, used for sanitary or hygienic purposes, or if it is disposable (oxygen, underpads, electrodes, etc.) Special order items will require a 50% deposit and are non-refundable.
8. Refuse all or part of your care and be informed of the expected consequences of such action.
9. Expect strict confidentiality of all information.
   To be informed with a reasonable time of anticipated termination or change of services, which services you will continue to need, and where you may obtain such services.
10. Participate in the consideration of ethical issues that arise in your care.
11. To make a formal complaint regarding equipment, care, privacy, or compliance without being subject to discrimination or reprisal and to be informed of the resolution within 14 days, please submit your complaint to: Tracy Hughes, 2520 Pegasus Drive, Bakersfield, CA 93308, 661-393-4877, tracy@kernmedicalsupply.com
12. Kern Medical Supply, LLC is accredited as a Home Medical Equipment supplier from HQAA. To make a complaint or request information about our company from HQAA, you may call  866-909-4722 Monday – Friday 9 am to 5 pm (ET). To make an inquiry or complaint to Medicare, you may call the Beneficiary Hotline at 800-633-4227
13. Kern Medical Supply, LLC maintains 24-hour availability by telephone. Qualified staff is always available to assist with equipment malfunction. Should a life-threatening situation arise, it is suggested the patient or caregiver dial “911” for professional emergency assistance.

RESPONSIBILITIES

1. Remain under a physician’s care while receiving services that require the order of a physician.
2. Provide accurate and complete information about your health history.
3. Notify Kern Medical Supply, LLC if the patient moves, receives a change in doctor’s orders, is admitted to a long-term facility, or is hospitalized.
4. Sign the required contents and releases for insurance billing.
5. Pay for all charges that Kern Medical Supply, LLC informs you that you are responsible for.
6. Notify Kern Medical Supply, LLC when changes in your condition occur which could affect your equipment needs. (revised oxygen liter flow, large weight change, etc.)
7. Request further information concerning anything that you do not understand. If the customer is unsure how to use the equipment safely or properly, please ask for more education.
8. Accept the consequences when you refuse care or are non-compliant.
9. Call a minimum of one working day in advance for all deliveries and pick-ups. The routine delivery week is defined as Monday through Friday.
10. Provide a safe environment in which your care can be given.
11. Return all rented equipment in the same condition in which it was received, normal wear and tear accepted.
12. Allow access to equipment if it needs to be repaired.
13. Cooperate with the Kern Medical Supply, LLC staff. Treat our staff with dignity, respect, and consideration.
14. Notify Kern Medical Supply, LLC if you are unable to keep an appointment.
15. Notify Kern Medical Supply, LLC if you are dissatisfied with our services.

MISSION STATEMENT

Kern Medical Supply, LLC improves the lives we serve through compassionate, knowledgeable durable medical equipment solutions.

PATIENT HEALTH INFORMATION-PRIVACY NOTICE

Please note that we maintain paper & electronic files that may contain private information about you that may include, but are not limited to your name, address, phone number, contact person, height & weight, diagnosis, prognosis, physician(s), prescriptions, plans of service & treatment, vital signs & other clinical impressions, insurance coverage(s), equipment rented & purchased from us, credit card number(s), dates of service, etc. We release, transfer & disclose the above information to third parties to facilitate appropriate provision & review of services & billing for our clients of record. These files are legal documents & are also used for education, evaluating the performance of our organization, marketing & planning purposes. We have measures in place to protect patient health information as required by law. These measures include but are not limited to, security precautions being in place in our buildings, vehicles, billing software, transactions with government entities, vendors, consultants, surveyors, your family or appointed representative & other appropriate parties, the transmission of data to third parties, telephonic & wireless communications, maintenance, retention & destruction of data, etc. You have the right to amend, restrict, revoke consent to release, examine or obtain copies of the data that we have in your file & have released to others upon request. If you have questions concerning any of the above, please contact Kern Medical Supply, LLC, 661-393-4877.