2015
Client/Patient Delivery Packet
Client/Patient Delivery Packet
Statement of Corporate Goal
MedStrive, LLC’s ultimate goal is to provide access to tools that help seniors to maintain or regain their
independence OR that assist the elder health caregiver in the provision of quality service. We, here at MedStrive,
LLC believe that access to the right tools promotes a higher quality of life for each patient served.
Corporate Information
MedStrive, LLC is a nationwide provider of durable medical equipment. We provide therapeutic medical equipment
ranging from supportive, orthopedic devices such as knee and back braces, to diabetic supplies, medical bedding,
and a wide range of traditional durable medical equipment.
The MedStrive, LLC corporate headquarters is in Greensboro, NC, and all development, distribution, and support are
centered there. Our expertly trained and dedicated Patient Care Coordinators are the head of our care team in the
field. They are responsible for educating the public on products offered, gathering information in regard to patient
needs, coordinating contact between the administrative staff and the patient’s existing support structure, and
customer service. Our administrative staff is second to none in their ability to help our clients/patients with
whatever questions or needs that may arise from the services we provide.
Thank you for allowing us the opportunity to serve you.
Corporate Contact Information
MedStrive, LLC
2514 Hilltop Drive
Sherman, TX 75090-2286
Toll-free:
Fax:
Email:
Website:
888-697-2488
888-573-7232
[email protected]
www.medstrive.com
Hours:
Monday – Friday
9:00AM – 5:00 PM
After hours answering system available.
MedStrive, LLC
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Client/Patient Delivery Packet
Emergency Planning for the Home Care Client/Patient
This section has been provided by MedStrive, LLC to help you plan your actions in case there is a natural disaster where you live. Many
areas of the United States are prone to natural disasters like hurricanes, tornadoes, floods, and earthquakes. Every client/patient receiving
care or services in the home should think about what they would do in the event of an emergency. Our goal is to help you plan so that we
can try to provide you with the best, most consistent service possible during the emergency.
Know What to Expect
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If you have recently moved to this area, take the time to find out what types of natural emergencies have occurred in the past, and what types might
be expected.
Find out what, if any, time of year these emergencies are more prevalent.
Find out when you should evacuate, and when you should not.
Your local Red Cross, local law enforcement agencies, local news and radio stations usually provide excellent information and tips for planning.
Know Where to Go
One of the most important pieces of information you should know is the location of the closest emergency shelter. These shelters are opened to the public
during voluntary and mandatory evacuation times. They are usually the safest place for you to go, other than a friend’s or relative’s home in an unaffected area.
Know What to Take with You
If you are going to a shelter, there will be restrictions on what items you can bring with you. Not all shelters have adequate storage facilities for medications
requiring refrigeration.
We recommend that you call ahead and find out which shelter in your area will let you bring your medications and medical supplies, in addition, let them know if
you will be using medical equipment that requires an electrical outlet.
During our planning for a natural emergency, we will contact you and deliver, if possible, at least one week’s worth of medication and supplies. Bring all your
medications and supplies with you to the shelter.
Reaching Us if There Are No Phones
How do you contact us during a natural emergency if the phone lines do not work? If there is warning of the emergency, such as a hurricane watch, we will
make every attempt to contact you and provide you with the number of our cellular phone. (Cellular phones frequently work even when the regular land phone
lines do not.)
If you have no way to call our cellular phone, you can try to reach us by having someone you know call us from his or her cellular phone. (Many times cellular
phone companies set up communication centers during natural disasters. If one is set up in your area, you can ask them to contact us.)
If the emergency was unforeseen, we will try to locate you by visiting your home, or by contacting your home nursing agency. If travel is restricted due to
damage from the emergency, we will try to contact you through local law enforcement agencies.
An Ounce of Prevention...
We would much rather prepare you for an emergency ahead of time than wait until it has happened and then send you the supplies you need.
To do this, we need for you to give us as much information as possible before the emergency. We may ask you for the name and phone number of a close family
member, or a close friend or neighbor.
We may ask you where you will go if an emergency occurs. Will you go to a shelter, or a relative’s home? If your doctor has instructed you to go to a hospital,
which one is it?
Having the address of your evacuation site, if it is in another city, may allow us to service your therapy needs through another company.
Helpful Tips
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Get a cooler and ice or freezer gel-packs to transport your medication.
Get all of your medication information and teaching modules together and take them with you if you evacuate.
Pack one week’s worth of supplies in a plastic-lined box or waterproof tote bag or tote box. Make sure the seal is watertight.
Make sure to put antibacterial soap and paper towels into your supply kit.
If possible, get waterless hand disinfectant from MedStrive, LLC or from a local store. It comes in very handy if you do not have running water.
If you are going to a friend’s or relative’s home during evacuation, leave their phone number and address with MedStrive, LLC and your home nursing
agency.
When you return to your home, contact your home nursing agency and MedStrive, LLC so we can visit and see what supplies you need.
For More information
There is much more to know about planning for and surviving during a natural emergency or disaster. To be ready for an emergency, contact your local
American Red Cross or Emergency Management Services agency.
An Important Reminder!!
During any emergency situation, if you are unable to contact our company and you are in need of your prescribed medication, equipment or supplies, you must
go to the nearest emergency room or other treatment facility for treatment.
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Client/Patient Delivery Packet
Advanced Directives
You can decide in advance what medical treatment you want to receive in the event you become physically or mentally unable to
communicate your wishes.
Your Rights as a Patient
All adults in hospitals, skilled nursing facilities, and health care settings have certain rights. For example, you have a right to confidentiality of
your personal and medical records and to know what treatment you will receive.
You also have another right. You have the right to prepare a document called an "advance directive," In one type of advance directive, you
state in advance what kind of treatment you want or do not want if you ever become mentally or physically unable to choose or communicate
your wishes. In a second type, you authorize another person to make those decisions for you if you become incapacitated. Federal law
requires hospitals, skilled nursing facilities, hospices, home health agencies and health maintenance organizations (HMOs) serving persons
covered by either Medicare or Medicaid to give you information about advance directives and explain your legal choices in making decisions
about medical care.
The law is intended to increase your control over medical treatment decisions. Be mindful, however, that state laws governing advance
directives do differ. The health care provider is required to give to you information about the laws with respect to advance directives for the
state in which the provider is located. If you reside in another state, you may wish to gather information about your state laws from another
source such as the office of the state attorney general.
What is an Advance Directive?
Generally, an advance directive is a written document you prepare stating how you want medical decisions made if you lose the ability to
make decisions for yourself. The two most commonly prepared advance directives are:
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a "Living Will"; and
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a "Durable Power of Attorney for Health Care."
The value of an advance directive is that it allows you to state your choices for health care or to name someone to make those choices for you,
if you become unable to make decisions about your medical treatment. In short, an advance directive ensures your right to accept or refuse
medical care. You can say "yes" to treatment you want, or "no" to treatment you don't want.
Living Will
A living will generally states the kind of medical care you want (or do not want) if you become unable to make your own decision. It is called a
living will because it takes effect while you are still living. Most states have their own living will forms, each somewhat different. It may also be
possible to complete and sign a preprinted living will form available in your own community, draw up your own form, or simply write a
statement of your preferences for treatment. You may also wish to speak to an attorney or your physician to be certain you have completed
the living will in a way that your wishes will be understood by your physician and to be certain you have completed the living will in a way that
your wishes will be understood and followed.
Durable Power of Attorney for Health Care
In many states, a durable power of attorney for health care is a signed, dated, and witnessed paper naming another person, such as a
husband, wife, daughter, son, or close friend, as your authorized spokesperson to make medical decisions for you if you should become unable
to make them for yourself. You can also include instructions about any treatment you want to avoid. Some states have specific laws allowing a
health care power of attorney, and provide printed forms.
Which is Better? A Living Will or a Durable Power of Attorney for Health Care
In some states, laws may make it better to have one or the other. It may also be possible to have both, or to combine them in a single
document that describes treatment choices in a variety of situations (ask your doctor about these) and names someone (called your "agent"
or "proxy") to make decisions for you, should you be unable to make decisions for yourself.
The law on honoring an advance directive from one state to another is unclear. However, because an advance directive specifies your wishes
regarding medical care, it may be honored wherever you are, if you make it known that you have an advance directive. But if you spend a
great deal of time in a state other than your home state, you may wish to consider having your advance directive meet the laws of both states,
as much as possible.
Advance Directives are not Required and may be Canceled at any Time
You do not have to prepare an advance directive if you do not want one. If you do prepare one, you have the right to change or cancel it at any
time. Any change or cancellation should be written, signed, and dated in accordance with state law, and copies should be given to your doctor,
or to others to whom you may have given copies of the original. In addition, some states allow you to change an advance directive by oral
statement.
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Client/Patient Delivery Packet
If you wish to cancel an advance directive while you are in the hospital, you should notify your doctor, your family, and others who may need
to know. Even without a change in writing, your wishes stated in person directly to your doctor generally carry more weight than a living will
or durable power of attorney, as long as you can decide for yourself and can communicate your wishes. But be sure to state your wishes
clearly and be sure that they are understood.
Make sure that someone, such as your lawyer or a family member, knows that you have an advance directive and knows where it is located.
You might also consider the following:
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If you have a durable power of attorney, give a copy or the original to your agent or proxy.
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Ask your physician to make your advance directive part of your permanent medical record.
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Keep a copy of your advance directive in a safe place where it can be found easily, if it is needed.
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Keep a small card in your purse or wallet stating that you have an advance directive, where it is located and who your agent or proxy
is, if you have named one.
Who Should Prepare an Advance Directive?
You may want to consider preparing an advance directive if:
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You want your physician or other health care provider to know the kind of medical care you want or don't want if you become
incapacitated.
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You want to relieve your family and friends of the responsibility, for making decisions regarding life-prolonging actions.
Additional Information
If you need help in preparing an advance directive, or if you would like more information, you may want to contact a lawyer, a nearby hospital,
hospice or long-term care facility, or your state attorney general’s office.
Information Provided by: U.S. Department of Health and Human Services Health Care Financing Administration Publication No. HCFA 02175
1995
Client/Patient Grievance/Complaint Policy
MedStrive, LLC will provide all clients/patients with written information listing a telephone number, contact person, and the Company’s
process for receiving, investigating, and resolving complaints about its services. This information is included in the Client/Patient Service
Agreement form and includes the phone number for registering a complaint with the Company’s accrediting body.
The following procedure details the steps to be taken when a client/patient grievance or complaint is received:
After receiving the concern, the Customer Service Supervisor will take the following steps:
1. Contact the person making the concern, if contact has not already been established.
2. Record information regarding the concern on the Complaint Log.
a. Date
b. Time
c. Description of concern (If equipment-related injury was involved, refer to Product Incident Procedure)
d. Name of individuals or description of product involved, and lot numbers (if applicable)
3. Determine what actions the caller feels should be initiated regarding the concern.
4. Arrange for the replacement of defective items if the concern involves a product.
5. Speak with involved employees as appropriate.
6. Attempt to resolve the concern to the client/patient’s satisfaction.
7. Report status of activities to client/patient within two business days following receipt of concern.
8. Each concern will be logged on the Complaint Log. All completed Complaint Forms are to be kept in a Complaint Log at the Location.
When a concern cannot be resolved within five (5) business days in the above-stated manner, the Complaint Form should be forwarded to the
President. The President will review the Complaint Form and collect additional data as required for the resolution of the concern, and will
respond to the concern within three (3) business days after the receipt of the Complaint Form.
Any concern received after normal working hours by the on-call personnel will be resolved before the next working day, if possible. If not, the
concern will be reported to the Customer Service Supervisor after receipt or the following morning. All concerns will be logged on the On-Call
Log Form and be written up as soon as possible on the Complaint Form. All concerns will be reviewed at the next QI meeting and reported to
the Board of Directors quarterly. In the event your complaint is not resolved to your satisfaction you can contact our accrediting organization The Compliance Team at (888) 291-5353.
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Client/Patient Delivery Packet
Confidentiality of Client/Patient Information
It is the policy of MedStrive, LLC that all information concerning client/patient service or services shall be treated confidentially. Each
client/patient will receive at start of service a HIPAA Notice of Privacy Practices, which describes how we may use and disclose Protected
Health Information (PHI).
1. Staff members will provide written information to clients/patients, and will discuss confidentiality of information with clients/patients, as
included in the Patient Rights & Responsibilities and Notice of Privacy Practices, during initial set-up.
2. Staff members will discuss client/patient-related information with Company personnel only on a need-to-know basis. Accessibility to a
client/patient’s record is to be limited to MedStrive, LLC staff including contracted organizations and billing personnel. At time of set-up, each
client/patient or that client/patient’s legal representation will sign HIPAA authorization forms, allowing MedStrive, LLC to obtain PHI from and
release PHI to involved physician(s), and other organizations or individuals involved in that client/patient’s care. In order to release a
client/patient’s PHI to any other entity, a Protected Health Information Privacy Agreement signed by the client/patient or that client/patient’s
legal representative must first be obtained.
3. All MedStrive, LLC staff members will receive training in confidentiality of client/patient information at time of orientation, and this training
will be noted on each employee’s orientation training form. This form will be placed in the employee’s personnel record. The employee will
be required to sign a Standards of Conduct agreement requiring that all confidential information, including passwords and any information
received or transmitted by computer, to remain confidential. All FAX transmissions of PHI require a cover sheet stating the confidentiality of
the information to be transmitted.
4. Reasonable measures will be taken to ensure the security of records against loss, defacement, tampering, and unauthorized use. Records
will be stored in a manner that minimizes the possibility of damage from fire and water.
5. Personal identifying information will be eliminated from Quality Improvement and other reports generated by MedStrive, LLC.
6. Client/Patient information will not be displayed in areas accessible to the public or unauthorized personnel. Any non-employee having
access to records (i.e. contracted individuals, billing services, etc.) are required to sign a Pledge of Confidentiality which will be kept as part of
their contract.
7. Original records may only be removed from the Location with the Compliance Officer’s permission or by court order. The Compliance
Officer is responsible for determining what portion of the record may be copied for client/patient care purposes, holding staff members
accountable for copies in their possession and ensuring that copies are returned to the Location for destruction.
8. Records will be available for review by licensing, regulatory, and accrediting bodies.
9. All staff members shall receive instruction in the Company’s procedure for handling client/patient concerns during initial orientation. Each
employee shall maintain competency in and understand this procedure.
Client/Patient Rights and Responsibilities
Patient Rights:
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The patient has the right to considerate and respectful service.
The patient has the right to obtain service without regard to race, creed, national origin, sex, age, disability, diagnosis or religious
affiliation.
Subject to applicable law, the patient has the right to confidentiality of all information pertaining to his/her medical equipment
service. Individuals or organizations not involved in the patient’s care may not have access to the information without the
patient’s written consent.
The patient has the right to make informed decisions about his/her care.
The patient has the right to reasonable continuity of care and service.
The patient has the right to voice grievances without fear of termination of service or other reprisal in the service process.
Patient Responsibilities:
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The patient should promptly notify the Home Medical Equipment Company of any equipment failure or damage.
The patient is responsible for any equipment that is lost or stolen while in their possession and should promptly notify MedStrive,
LLC in such instances.
The patient should promptly notify MedStrive, LLC of any changes to their address or telephone.
The patient should promptly notify MedStrive, LLC of any changes concerning their physician.
The patient should notify MedStrive, LLC of discontinuance of use.
Except where contrary to federal or state law, the patient is responsible for any equipment rental and sale charges which the
patient’s insurance company/companies does not pay.
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Client/Patient Delivery Packet
Medicare DMEPOS Supplier Standards
MedStrive, LLC adheres to the following standards as required by the Centers for Medicare and Medicaid Services:
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A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
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.
An authorized individual (one whose signature is binding) must sign the application for billing privileges.
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.
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.
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.
A supplier must maintain a physical facility on an appropriate site.
A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards.
The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and
posted hours of operation.
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 or cell phone is prohibited.
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.
A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits
suppliers from calling beneficiaries in order to solicit new business.
A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of
delivery.
A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicarecovered items it has rented to beneficiaries.
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.
A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
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.
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.
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.
A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.
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). Implementation
Date – October 1, 2009
All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in
order to bill Medicare.
All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are
seeking accreditation.
Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation Date – May 4, 2009
A supplier must obtain oxygen from a state- licensed oxygen supplier.
A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f).
DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.
DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.
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Client/Patient Delivery Packet
How to Make Your Home Safe for Medical Care
At MedStrive, LLC, we want to make sure that your home medical treatment is done conveniently and safely. Many of our clients/patients
are limited in strength, or unsteady on their feet. Some are wheelchair or bed-bound. These pages are written to give our Patients some
easy and helpful tips on how to make the home safe for home care.
Fire Safety and Prevention
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Smoke detectors should be installed in your home. Make sure you check the batteries at least once a year.
If appropriate, you may consider carbon monoxide detectors as well. Ask your local fire department if you should have one in your home.
Have a fire extinguisher in your home, and have it tested regularly to make sure it is still charged and in working order.
Have a plan for escape in the event of a fire. Discuss this plan with your family.
If you use oxygen in your home, make sure you understand the hazards of smoking near oxygen. Review the precautions. If you aren’t
sure, ask your oxygen provider what they are.
If you are using electrical medical equipment, make sure to review the instruction sheets for that equipment. Read the section on
electrical safety.
Electrical Safety
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Make sure that all medical equipment is plugged into a properly grounded electrical outlet.
If you have to use a three-prong adapter, make sure it is properly installed by attaching the ground wire to the plug outlet screw.
Use only good quality outlet “extenders” or “power strips” with internal Circuit breakers. Don’t use cheap extension cords.
Safety in the Bathroom
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Because of the smooth surfaces, the bathroom can be a very dangerous place, especially for persons who are unsteady.
Use non-slip rugs on the floor to prevent slipping.
Install a grab-bar on the shower wall, and non-slip footing strips inside the tub or shower.
Ask your medical equipment provider about a shower bench you can sit on in the shower.
If you have difficulty sitting and getting up, ask about a raised toilet seat with arm supports to make it easier to get on and off the
commode.
If you have problems sensing hot and cold, you should consider lowering the temperature setting of your water heater so you don’t
accidentally scald yourself without realizing it.
Safety in the Bedroom
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It’s important to arrange a safe, well-planned and comfortable bedroom since a lot of your recuperation and home therapy may occur
there.
Ask your home medical provider about a hospital bed. These beds raise and lower so you can sit up, recline, and adjust your knees. A
variety of tables and supports are also available so you can eat, exercise, and read in bed.
Bed rails may be a good idea, especially if you have a tendency to roll in bed at night.
If you have difficulty walking, inquire about a bedside commode so you don’t have to walk to the bathroom to use the toilet.
Make sure you can easily reach the light switches, and other important things you might need through the day or night.
Install night-lights to help you find your way in the dark at night.
If you are using an IV pole for your IV or enteral therapy, make sure that all furniture, loose carpets, and electrical cords are out of the
way so you do not trip and fall while walking with the pole.
Safety in the Kitchen
Your kitchen should be organized so you can easily reach and use the common items, especially during your recuperation while you are still a
bit weak:
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Have a friend or health care worker remove all common small appliances and utensils from cabinets, and place them on your counters
where you can easily use them.
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Have a chair brought into the kitchen to the counter work area if you have difficulty standing.
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Make sure you are careful lifting pots and pans. Not only might they be hot, but they can be heavy as well. Use padded mitts to firmly
grasp pans and pots on both sides.
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Ask your kitchen or hardware store about utensils for manually impaired or arthritic persons, including:
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Basic electric can openers
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Bottle and jar openers
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Large-handled utensils
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When working at your stove, be very careful that intravenous, tube feeding tubing, or oxygen tubing do not hang over the heat. They can
be flammable.
Getting Around Safely
If you are now using assistant devices for ambulating (walking), here are some key points:
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Install permanent or temporary guardrails on stairs to give you additional support if you are using a cane or are unsteady.
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Client/Patient Delivery Packet
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If you are using a walker, make sure that furniture and walkways are arranged to give you enough room.
If you are using a walker or wheelchair, you may need a ramp for getting into or out of the house. Ramps can be purchased ready-made,
or may be constructed for you. Talk to your home medical equipment provider about available options.
What To Do If You Get Hurt … In case of emergency, contact: Fire, Police, Ambulance: 911
Hospital:________________________________________________ Phone:________________________________________________
Home Care Agency:_______________________________________ Phone:________________________________________________
Doctor:_________________________________________________ Phone:________________________________________________
MedStrive, LLC: Toll-Free: (888) 697-2488
If you have any questions about safety that are not in this booklet, please call us and we will be happy to give you recommendations for your
individual needs.
Warranty Information (Sale Equipment Only)
Thank you for choosing MedStrive, LLC to meet your Medical Device needs. We here at MedStrive work hard to provide innovative adaptive
equipment solutions that assist you in achieving a higher quality of life. We want your experience with MedStrive, LLC to be as efficient and
rewarding as possible.
All products provided by MedStrive, LLC are under warranty for a period of one (1) year from the date of delivery. During that period,
MedStrive, LLC will repair or replace any damaged item free of charge to the client/patient.
It is also MedStrive, LLC’s policy to accept any returns up to, and not exceeding, 90 days from the date of delivery.
If you have any questions, comments or concerns, please do not hesitate to contact our Customer Service Department at (888) 697-2488.
MedStrive, LLC
2514 Hilltop Drive
Sherman, TX 75090-2286
Toll-free:
Fax:
Email:
Website:
888-697-2488
888-573-7232
[email protected]
www.medstrive.com
MedStrive, LLC
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Client/Patient Delivery Packet
I acknowledge receipt of Medstrive, LLC., Client Handouts as well as instruction regarding the care and use
of the equipment included in this shipment.
I have authorized Medstrive, LLC., under the direction of my physician, to provide home medical
equipment and services as provided as prescribed by my physician.
I authorize Medstrive, LLC., to bill my insurance on my behalf for any equipment or supplies provided to
me by Medstrive, LLC.,
Finally, I acknowledge the functionality of the equipment being provided.
_____________________________________________
Patient or Authorized Party Signature
_______________________________
Date:
_____________________________________________
Printed
MedStrive, LLC
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