AKT Medical, LLC
15289 Stony Creek Way
Noblesville, IN 46060

elite seat®   
Online Patient Information and Equipment Agreement

If you would rather download the Equipment Agreement and fax to AKT Medical download it here and fax to:

AKT Medical, LLC @ (317) 770 - 8360

IN ORDER TO PROCESS AN elite seat® FOR A PATIENT, PLEASE FOLLOW THE INSTRUCTIONS BELOW:

  1. Fill out all of the forms below with the correct information.
  2. Read over the two terms and conditions, and once all information and you have agreed to the terms press submit
  3. If you have made any mistakes a small red X will be displayed. Fix these errors until you see a message confirming that your information has been received.


AKT Medical will contact the patient's insurance company and determine the level of benefit that the patient is entitled.  AKT Medical will notify the patient, the physical therapist (if involved) and the patient's physician and disclose the insurance company's decision in relation to the elite seat®.  If the elite seat® is approved, AKT Medical will coordinate with the patient, the physician and/or physical therapy office to have the elite seat® delivered.

* = optional

Patient Information

Insured's Name

 Home #
Cell # * Work # * - - -
Address City
State Zip Code
Email Date of Birth
Sex    

Physician Information
Physician Address
City State
Zip Telephone # - - -
Email * Physical Therapy Clinic *
Physical Therapist * Address *
City * State *
Zip * Telephone *
Email *    

Insurance Information
Insurance Company Policy Group # *
Policy Number * Patient ID *
Claim # Telephone # - - -
Date of Injury ex. September 01 1999 Case Manager Name *
Phone * - - - Email *

Assignment of Benefits
I authorize my physician to release to AKT Medical, and for AKT Medical to release to my insurer, any information needed to process a claim.  I request that payment of authorized benefits be made on my behalf to AKT Medical.  I authorize AKT Medical to submit a claim to any of the insurers as may be required.  I understand that I am responsible for paying any amounts, including deductibles and co-payments that are not covered by my insurance prior to or upon receiving the unit.  AKT Medical will notify me of my covered benefit and its estimate of my obligation of an uncovered amount after contacting my insurance company.  I accept the terms of this agreement and have read the warranty and return information.
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Patient Notice

  

As part of your treatment plan, your Health Care Provider has deemed it €œmedically necessary€ for you to have the elite seat®.  Based on your diagnosis and treatment protocol, the elite seat® may be rented.   AKT Medical, LLC will bill your insurance carrier for the elite seat® you receive.  Depending on your coverage, you may be responsible for some or all of the costs.  The amount not covered by your insurance plan will be billed to you.  Private pay options are always available.

Manufacturer's Warranty: AKT Medical shall turn over, assign to, or pass through to the patient the manufacturer's warrant on the elite seat®.  Any defective or malfunctioning device will be replaced with a similar device.  For questions relating to warranty information including but not limited to product performance, repair or replacement, please call (317) 770-8355 or e-mail claims@aktmedical.com  Medicare beneficiaries receive unconditional replacement or repair of defective products within a twelve month manufacturer warranty period, excluding normal wear and tear.

HIPAA Privacy Practice:
AKT Medical, LLC
PRIVACY NOTICE
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.

If you have any questions about this notice, please contact the Privacy Officer.
Each time you visit a physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information.  This notice applies to all of the records of your care generated by this practice.
Our Responsibilities
We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices.  We will abide by the terms of this notice.
Uses and Disclosures
How we may use and disclose Medical Information about you.
The following categories describe examples of the way we use and disclose medical information:
For Treatment:  We may use medical information about you to provide treatment or services.  We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you.  For example, a doctor treating you for an infection may need to know if you have diabetes because diabetes may slow the healing process. 
For Payment:  We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer.  For example, we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment. 
For Health Care Operations:  Members of the medical staff may use information in your health record to assess the care and outcomes in your case and others like it.  The results will then be used to continually improve the quality of care for all patients we serve.  For example, we may combine medical information about many patients to evaluate the need for new services or treatment.  We may disclose information to doctors, nurses, and others for educational purposes. 
We may also use and disclose protected health information:

  • To remind you that you have an appointment for medical care, or to advise of test results;
  • To assess your satisfaction with our services;
  • To tell you about possible treatment alternatives;
  • To tell you about health€“related benefits or services; and
  • For population based activities relating to improving health or reducing health care costs.

Business Associates:  There are some services provided in our organization through contracts with business associates.  When these services are contracted, we may disclose your health information to our business associate so that they can perform the service we require and bill you or your third-party payer for services rendered.  To protect your health information, however, we require the business associate to appropriately safeguard your information.
Research:  If you are participating in a research project, we may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research.
Future Communications:  We may communicate to you via newsletters, our web site, mail outs or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives or activities our practice is participating.
Affiliated Covered Entity:  Protected health information will be made available to hospital personnel as necessary to carry out treatment, payment and health care operations.  Caregivers at other facilities may have access to protected health information at their locations to assist in reviewing past treatment information as it may affect treatment at this time.  Please contact the Privacy Officer for further information on the specific sites included in this affiliated covered entity.
As required by law, we may also use and disclose health information for the following types of entities, including but not limited to:

  • Food and Drug Administration
  • Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability
  • Correctional Institutions
  • Workers Compensation Agents
  • Organ and Tissue Donation Organizations
  • Military Command Authorities
  • Health Oversight Agencies
  • Funeral Directors, Coroners and Medical Directors
  • National Security and Intelligence Agencies
  • Protective Services for the President and Others

Law Enforcement/Legal Proceedings:  We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

 

Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or office that compiled it, you have the Right to:

  • Inspect and Copy:  You have the right to inspect and copy medical information that may be used to make decisions about your care.  Usually, this includes medical and billing records, but does not include psychotherapy notes.  We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed.  Another licensed health care professional chosen by the practice will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.
  • Amend:  If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept by or for the practice.  We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.
  • An Accounting of Disclosures:  You have the right to request an accounting of disclosures.  This is a list of certain disclosures we make of your medical information for purposes other than treatment, payment or health care operations.
  • Request Restrictions:  You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations.  You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.  For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

  • Request Confidential Communications:  You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you may ask that we contact you at work or by U.S. Mail.  The practice will grant requests for confidential communications at alternative locations and/or via alternative means only if the request is submitted in writing and the written request includes a mailing address where the individual will receive bills for services rendered by the practice and related correspondence regarding payment for services.  Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response.  We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.
  • A Paper Copy of This Notice:  You have the right to a paper copy of this notice.  You may ask us to give you a copy of this notice at any time.  Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To exercise any of your rights, please obtain the required forms from the Site Office Manager and submit your request in writing. 

CHANGES TO THIS NOTICE

We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future.  The current notice will be posted in each office and include the effective date.  In addition, each time you register for treatment, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the practice by contacting the number below and asking for the Privacy Officer or with the Secretary of the Department of Health and Human Services.  All complaints must be submitted in writing.
You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission.  If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.  You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

 

 

You have been provided with the following information:

  • Information about the Manufacturers Warranty on the elite seat®. 
  • Information about your Rights to Privacy Practices, Equipment Education and Supplier Standards.
  • You understand that your claim will be submitted to Medicare / Insurance.  Medicare / Insurance may not pay for this item and you will be responsible for the bill if it is not covered by your insurance provider.  You may contact AKT Medical, LLC at (317) 770-8355 to make payment arrangements.

 

I agree to be personally and fully responsible for payment. That is, I will pay personally, or out of pocket or through any insurance.

If I have any questions or concerns or need to return a rented elite seat®, I can call AKT Medical, LLC at (317) 770-8355.
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