instructions during the initial set-up. Purchased Equipment and Warranties New equipment is subject to the manufacturer’s warranty. Refer to the warranty information provided to you at the time of purchase. All warranties will be honored under applicable state laws.
instructions during the initial set-up. Purchased Equipment and Warranties New equipment is subject to the manufacturer’s warranty. Refer to the warranty information provided to you at the time of purchase. All warranties will be honored under applicable state laws. Service and Repair
To Advance Healthcare for a Better Health Customer Information Handbook www.hhme.com | 708-422-2300 | Fax: 708-422-5966 Evergreen Park Office & Retail Store 3518 W. 95th St. Evergreen Park, IL 60805 West Suburban Office - Oakbrook 2625 Butterfield Road, Suite 221W Oak Brook, IL 60523 Customer Information Handout Welcome! Thank you for choosing Hayat Home Medical Equipment as your home medical equipment supplier. This handout provides you with information for your overall health care. Please keep this handout for reference and call our office at any time if you have questions. In specific, this handout shares information with you about the following: Our commitment in providing quality services and products Mission Statement Geographic Coverage Compliance & Commitment Scope of Service Service, Delivery, & Warranty Patient grievance procedure Notice of privacy practices Patient Bill of rights and responsibilities Medicare supplier standards Cleaning procedure for our products Important Electrical Safeguards Special Electrical Needs Financial Policy Billing and payment policies Advance Medical Directives Patient Communication Form Our Commitment In Providing Quality Services And Products We are dedicated to providing home medical equipment services to our customers with the utmost quality and professionalism. We accept only those customers whose home health needs, as identified by the referring source, can be met by the services we offer. We not only provide quality home care products; we genuinely care for the customers we serve. Our services include the following: 24 hours, 7 days-a-week emergency services Customer instruction and training on all products provided Experienced clinical, delivery and office staff to assist you Routine delivery and set-up Assistance with your reimbursement billing questions, in relation to your insurance company requirements. At the end of this handout you will be asked to acknowledge that you received this handout and that you have read and understand the information we have provided to you. Mission Statement To be the leading regional provider of home health and institutional products by demonstrating our commitment to clinical excellence, customer service and by delivering a wide range of specialty services ensuring quality care for all patients and being a reliable partner to the health care community. Geographic Coverage We serve all of Chicago Metropolitan area in Illinois within the counties of Cook & DuPage only. Compliance and Commitment Hayat Home Medical Equipment is committed to complying with all federal and state regulations, and is accredited by Joint Commission. If you have any questions or concerns regarding any of our activities, please contact our office at 708-422-2300. Respiratory Equipment Oxygen Portable Oxygen Nebulizers C-PAP's Bi-PAP's Oximeters Non-Invasive Ventilators Afflovest SCOPE OF SERVICES Medical Equipment Hospital Beds Walkers Walker Accessories Quad Canes Hoyer Lifts Trapezes Commodes Bathroom Safety Aids Wheelchairs Specialty Equipment Low Air Loss Overlays Alternating Pressure Mattresses Compression Hoses Orthopedic Supplies POV Lift Chairs Diagnostic Equipment Bariatric Equipment Hospital Beds Wheelchairs Commodes Bath Aid Walkers Trapezes Low Air Loss Mattresses Service, Delivery and Warranty Evergreen Park Hours Monday Friday 8:30 A.M. to 7:00 P.M. Saturday 10:00 A.M. to 3:00 P.M. Oak Brook Hours Monday Friday 10:00 A.M. to 6:00 P.M. 24 hour emergency service is available for equipment related emergencies that may arise after hours, on weekends and/or holidays Delivery Deliveries are provided on purchases and/or rentals. It is preferable that routine and repeat orders be called in 24 hours in advance. Rental Equipment Customers are responsible for routine maintenance and cleaning provide according to the instructions during the initial set-up. Purchased Equipment and Warranties New equipment is subject to the manufacturer's warranty. Refer to the warranty information provided to you at the time of purchase. All warranties will be honored under applicable state laws. Service and Repair Service or repair on equipment purchased from our company that is no longer covered by the manufacturer's warranty will be subject to current labor chargers. The customer will be informed of their responsibilities regarding the ongoing care and service of the equipment and will be provided with maintenance instructions and how to obtain any service required. All service and repair must be scheduled by calling the office during regular business hours. Patient Grievance Procedure All of our customers are very important to us. So that we can resolve any problems that arise in a rapid and effective manner, we have developed the following patient grievance procedure. 1. If you have a concern, you can speak to the person delivering your equipment at the next visit. 2. If you do not want to wait to speak to the delivery person or if the issue you have involves our employee, you can call our office and speak with the operations manager, or fill out the form on the back of this handbook. Notice of Privacy Practices This notice describes how the medical information about you may be used and disclosed, and how you can get access to this information. PLEASE READ THIS NOTICE CAREFULLY. EFFECTIVE April 14, 2003, Our Commitment to Your Privacy Hayat Home Medical Equipment 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 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. To summarize, this notice provides you with the following information: How we may use and disclose your identifiable health information Your privacy rights in your identifiable health information Our obligations concerning the use and disclosure of your identifiable health information. The terms of this notice apply to all records containing your identifiable health information that are created or retained by our organization. We reserve the right to revise or amend our notice of privacy practice. Any revision or amendment to this notice will be effective for all of your records our organization has created or maintained in the past, and for any of your records we may create in the future. If you have any questions about this notice, please contact Hayat Home Medical Equipment We may use and disclose your information in the following ways: 1. Treatment. We may use your identifiable information to provide supplies and services to you. For example, we ask you to provide us with such information as body weight, height, etc. Various members of the Hayat Home Medical Equipment's staff may use or disclose your identifiable health information in order to provide supplies and services to you or to assist others in your treatment. Additionally, we may disclose your identifiable health information to others who may assist in your care, such as your physician, therapists, spouse, children or parents. 2. Payment. We may use and disclose your identifiable health information in order to bill and collect payment for the services and supplies you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for your supplies and/or services. We may also use and disclose your identifiable health information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your identifiable health information to bill you directly for services and supplies. 3. Health Care Operations. We may use and disclose your identifiable health information to operate our business. As examples of the ways in which we may use and disclose your health information for our operations, we may use your health information to evaluate the quality of care you receive from us, or to conduct cost-management and business planning activities for our business. 4. Appointment Reminders. We may use and disclose your identifiable health information to contact you and remind you of visits/deliveries. 5. Health-Related Benefits and Services. We may use your identifiable health information to inform you of health-related benefits or services that may be of interest to you. 6. Release of Information to Family / Friends. We may release your identifiable health information to a friend or family member that is helping you pay for your health care, or who assists in taking care of you. 7. Disclosures Required By Law. We will use and disclose your identifiable health information when we are required to do so by federal, state or local law. Use and Disclosure of Your Identifiable Health Information in Certain Special Circumstances The following categories describe unique scenarios in which we may use or disclose your identifiable health information: 1. Public Health Risk. We may disclose your identifiable health information to public health authorities that are authorized by law to collect information for the purpose of: o Maintaining vital records, such as births and deaths o Reporting child abuse or neglect o Preventing or controlling disease, injury or disability o Notifying a person regarding a potential exposure to a communicable disease o Notifying a person regarding a potential risk for spreading or contracting a disease or condition o Reporting reactions to drugs or problems with products or devices o Notifying individuals if a product or device they may be using has been recalled o Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information. 2. Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general. 3. Lawsuits and Similar Proceedings. We may use and disclose your identifiable health information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We may also disclose your identifiable health in response to a discovery request, subpoena, or other lawful process by another party involved in a dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. 4. Law Enforcement. We may release identifiable health information if asked to do so by a law enforcement official: o Regarding a crime victim in certain situations, if we are unable to obtain the person's agreement o Concerning a death, we believe might have resulted from criminal conduct o Regarding criminal conduct in our offices o In response to a warrant, summons, court order, subpoena, or similar legal process o To identify/locate a suspect, material witness, fugitive or missing person o In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator) 5. Serious Threats to Health or Safety. We may use and disclose your identifiable health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. 6. Military. We may disclose your identifiable health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command facilities. 7. National Security. We may disclose your identifiable health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your identifiable health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. 8. Inmates. We may disclose your identifiable health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals. 9. Workers Compensation. We may release your identifiable health information for workers compensation and similar programs. 10. Coroners, Medical Examiners and Funeral Directors. We may disclose health information to a coroner or medical examiner. We may also disclose medical information to funeral directors consistent with applicable law to carry out their duties. 11. Organ Procurement Organizations. Consistent with applicable law, we may disclose health information to organ procurement organizations or entities engaged in the procurement, banking, or the transportation of organs for the purpose of tissue donation and transplant. 12. Research. We may disclose information to researchers when their research has been approved by an Institutional Review Board or Privacy Board that has reviewed the research proposal and established protocols to ensure the privacy of your healthcare information. Your Rights Regarding Your Identifiable Health Information 1. Confidential Communications. You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to us, specifying the requested method of contact or location where you wish to be contacted. We will accommodate reasonable requests. You do not need to give a reason for your request. 2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your identifiable health information for treatment, payment or health care operations. Additionally, you have the right to request we limit our disclosure of your identifiable health care information to individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your identifiable health information, you must make your request in writing to us. Your request must describe in clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our use, disclosure or both; and (c) to whom you want the limits to apply. 3. Inspection and Copies. You have the right to inspect and obtain a copy of the identifiable health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to us in order to inspect and/or obtain a copy of your identifiable health information. We may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. We may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Reviews will be conducted by another licensed health care professional chosen by us. 4. Amendment. You may ask us to amend your health information if you believe it to be incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for us. To request an amendment, your request must be made in and submitted to us in writing. You must provide us with a reason that supports your request for amendment. We will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is: (a) accurate and correct; (b) not part of the identifiable health information kept by or for us; (c) not part of the identifiable health information which you would be permitted to inspect and copy; (d) not created by us, unless the individual or entity that created the information is not available to amend the information. 5. Accounting of Disclosures. All of our patients have the right to request an accounting of disclosures. An accounting of disclosures is a list of certain disclosures we have made of your identifiable health information. In order to obtain an accounting of disclosures, you must submit your request in writing to our office. All requests for an accounting of disclosures must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but we may charge you for additional lists within the same 12-month period. We will notify you of the cost involved with additional requests, and you may withdraw your request before you incur any costs. 6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact our office. 7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us or with the Office of Civil Rights. All complaints must be in writing. You will not be penalized for filing a complaint. 8. Right to Provide an Authorization for Other Uses and Disclosures. We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your identifiable health information for the reasons described in the authorization. Please note, we are required to retain records of your care. Patient's Bill of Rights and Responsibilities You have the right to: 1. Considerate and respectful service. 2. Obtain service without regard to race, creed, national origin, sex, age, disability or illness, or religious affiliation. 3. Confidentiality of all information pertaining to you, your medical care and service. 4. A timely response to your request for service and to expect continuity of services. 5. Select the home medical equipment supplier of your choice. 6. Make informed decisions regarding your care planning. 7. Be told what service will be provided in your home, how often and by whom. 8. An explanation of charges including policy for payment. 9. Agree to or refuse any part of the plan of service or plan of care. 10. Voice grievances without fear of termination of service or other reprisals. 11. Have your wishes honored as they apply to advance directives you have formulated. 12. Have your pain assessed as it relates to the services provided. 13. Have your communication needs met. You have the responsibility to: 1. Ask questions about any part of the plan of service or plan of care that you do not understand. 2. Protect the equipment from fire, cigarette smoke, water, theft or other damage while it is in your possession. 3. Use the equipment for the purpose for which it was prescribed, following instructions provided for use, handling care, safety and cleaning. 4. Supply us with needed insurance information necessary to obtain payment for services and assume responsibility for charges not covered. You are responsible for settlement in full of your account. 5. Be at home for scheduled service visits or notify us in advance to make other arrangements. 6. Notify us immediately of: a. Equipment failure, damage or need of supplies. b. Any change in your prescription or physician. c. Any change or loss in insurance coverage. d. Any change of address or telephone number, whether permanent or temporary. e. Discontinued equipment or services. 7. Be respectful of the property owned by our company and considerate of our personnel. 8. Contact us if you acquire an infectious disease during the time we provide services. Medicare Supplier Standards 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. An authorized individual (one whose signature is binding) must sign the enrollment application for billing privileges. 4. A supplier must fill orders from its own inventory or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs or from 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 squarefeet 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 and must instruct beneficiaries on 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 directly or through a service contract with another company 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 Medicarecovered 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 implementing 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 of 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 C.F.R. 424.57(c). 27.A supplier must obtain oxygen from a state-licensed oxygen provider. 28.A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 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. NOTE: Please contact our office with any further questions about your rights under Medicare regulations. Cleaning Procedures for Our Products Hayat Home Medical Equipment ensures that at the time of delivery, pre-used equipment has been cleaned and sterilized. When this equipment is picked up it will be contained and transported to our warehouse for a thorough cleaning and disinfecting. While this product is in your home, please follow the steps below to keep clean. 1. Unplug all electrical equipment before cleaning. 2. All of our equipment can be cleaned by proper direction given on the initial time of set up. 3. Never use ammonia or bleach solution while cleaning the equipment. Important Electrical Safeguards Improper Use of This Equipment Will Result In Electrical Shock and/or Damage to the Equipment. 1. Equipment should be plug in to the wall outlet or a power strip. Do not use extension cords with the equipment. 2. Always ensure that this equipment is properly grounded. Per Article 250 of the National Electrical Code this equipment has been supplied with a three-pronged power cord, which should be inserted into a grounded receptacle, or used with a properly grounded adaptor. 3. Some forms of transportable equipment may be used outdoors and are powered by an auxiliary power source (batteries). Non-transportable equipment should be used indoors only. 4. Do not use this equipment near water. 5. Do not place liquid on or around electrical equipment. 6. Always place equipment on a firm, stable base. 7. Report any problems with the equipment. If the equipment is not working properly or has been damaged please contact us at 708-422-2300. FOR OUR CUSTOMERS WITH SPECIAL ELECTRICAL NEEDS In order to request "priority service" from your utility in the event of a power outage follow these three easy steps to have your account flagged. 1. Obtain a letter from your doctor stating the need for priority service due to "life support" equipment. 2. Call your local utility for your local district's office address. 3. Mail the doctors letter to your utility district's office. Financial Policy All new equipment setups going on account require prior verification of insurance coverage before equipment is setup. If this is not possible due to a weekend or other after-hours setup, verification must be done on the next business day. We do not guarantee coverage of or payment of insurance claims. We do not guarantee any time frame for processing of insurance claims or subsequent billing from our office. It will be done in a timely manner. Insurance Coverage Customer's Responsibility: Provide us with all insurance information necessary to file your claim. Notify our office of any changes or loss of insurance coverage. Pay all deductible and balance remaining after secondary insurance is filed. The customer is responsible for payment in full of all claims not covered by insurance. You will be informed before delivery if we know that an item is not covered and assignment will not be accepted. Any arrangements or agreement for payment other than those described above must have approval from the operations manager. Special terms and approval signature must be documented on original paperwork. Medicare Claims Durable medical equipment is covered under your Medicare Part B benefit. If Medicare is your insurance carrier and denies payment, you will be notified. At that time, if you wish to keep the equipment it may be converted to private rental. In most cases, if you have supplemental insurance, the deductible amount and the 20% may be paid by other insurance. We will follow through with the appeal process on Medicare claims that are denied. However, this will only be done on non-assigned claims at the customer's request. The customer is also advised that: Inexpensive, routinely purchased durable medical equipment may be rented or purchased. There will be a minimum of one-month rental on all equipment rentals. Rental charges will be assessed until we are notified to pick up the equipment. Any charges incidental to the use or operation of the equipment (such as electricity) is the responsibility of the customer. There is no charge for delivery or pickup of rental equipment. All claims, assigned or non-assigned, will be filed on behalf of the patient. Billing and Payment Policy Customers are responsible for payment in accordance with our company's terms. Assignment of benefits to a third party does not relieve the customer of the obligation to ensure full payment. Billing third party payers is not an obligation, but rather a service we offer if all necessary billing information and signatures are provided. Medicare We may accept Medicare Part B assignment, billing Medicare directly for 80% of allowed charges and billing the beneficiary the 20% payment and any deductible. We offer Electronic Claims Transmission for billing non-assigned orders. A copy of your Health Insurance Card is necessary. Medicaid We may provide equipment to Medicaid recipients upon verification and approval of coverage status and medical justification. A copy of your IL Medicaid Identification Card and personal ID are required. Private Insurance We may bill private insurance carriers upon verification and approval of coverage status and medical justification. You are responsible for providing our billing department with all necessary insurance information. You are also responsible for notifying us any insurance changes. A copy of your insurance card and personal ID are required. Remember, billing a third-party insurance does not guarantee payment. Financial responsibility remains with you, the patient. Advance Medical Directives Advance Medical Directives are legal documents that allow you to give directions for your future medical care. They can assist you in communicating your choices should you become physically or mentally unable to do so. Two types of advance directives are living wills and durable power of attorney. You can use advance directives to limit certain life prolonging measures when there is little or no choice of recovery. For example, you may wish to address: CPR Cardiopulmonary Resuscitation IV Therapies Feeding Tubes Ventilators Dialysis Pain Relief Your choices regarding your medical care should be discussed with your family, friends, physicians, clergy and attorney. At Hayat Home Medical Equipment, our employees are not certified to administer CPR. If a situation would arise, the employee is instructed to call 911, unless you, your physician or legal representative informs us otherwise. Please take the time to inform our office of any existing advance directives. Information regarding your advance directives can be given to our Customer Service Department. We have included a Patient Communication Form for you to complete should you wish to contact us. You can mail this form to: Hayat Home Medical Equipment Attn: General Manager 3518 W. 95th St. Evergreen Park, IL 60805 Patient Communication Form Hayat Home Medical Equipment strives to provide the highest quality health care services to all our patients. That is why your concerns are our concerns. To ensure that our services meet your complete satisfaction, we ask you to describe any complaint, problem, concern or compliment you may have. After completing this form, please tear this page out of the handout and mail to your service location. The operations manager will research your concern in order to resolve all complaints and / or problems. We assist your candid comments as well as your assistance in helping us to continually improve our service(s) to our valued customers. Name: Date of Service: Telephone Number: ( ) - Please describe you compliment / concern: Equipment Name of driver We are also certified by The Joint Commission for high quality standard care. If you would like register a complaint or comment, they can be reached at the web www.jointcommission.org, by email at customerservice@jointcommission.org.or by phone at 800-994-6610. ******************OFFICE USE ONLY************************ Action taken/Resolution: Date Resolved: Manager's signature: Date:Microsoft Word for Office 365 Microsoft Word for Office 365