Healthcare Product Guide

HEALTHCARE PRODUCT GUIDE

Provider Name:   Guide Issue Date:

Purpose: This Healthcare Product Guide summarizes available medical devices and supplies, intended indications, common risks, typical benefits, ordering and billing practices, training expectations, and patient responsibilities. This Guide does not replace individualized medical advice from your prescriber. Patient must follow prescriber instructions and product labeling.

Patient Information

Insurance & Billing

Billing Notes: Products may require prior authorization. Patient acknowledges responsibility for co-payments, deductibles, and non-covered charges. Provider will attempt to verify benefits and obtain authorizations when requested by prescriber.

Medical History (Relevant to Product Selection)

Available Products — Selection & Details

The following is a non-exhaustive list of commonly provided products. Provider will supply product-specific labeling and manufacturer instructions with delivery. Patient should retain all labeling and warranty documents.

Training, Delivery & Maintenance

Training Provided (check all that apply):
In-person demonstration    Written instructions    Instructional video reference available    Telephonic coaching

Expected Delivery Method:   Expected Delivery Date:

Maintenance and Repair: Provider will supply warranty and repair procedures where applicable. Patient must report malfunction immediately. Some repairs may be billable if outside warranty or due to misuse.

Risks, Benefits & Patient Responsibilities

Benefits: Products may improve symptoms, function, or monitoring capability as indicated by your prescriber. Risks: All products carry potential adverse effects such as device failure, skin injury, infection, incorrect therapy delivery, and other complications. Patient must follow instructions for safe use, cleaning, and storage.

Patient Acknowledgements (check each to confirm understanding):

I have received a copy of this Healthcare Product Guide.

I have been provided with instructions/training appropriate to the selected product(s).

I understand the risks and benefits associated with selected product(s).

I understand my financial responsibility for non-covered items, copays, and deductibles.

Privacy & Authorization

By signing below, I authorize the Provider and its agents to use and disclose medical and billing information as necessary to advise on, order, deliver, bill, and service the selected product(s). I understand such disclosures are limited to the minimum necessary for these purposes. This authorization is voluntary and may be revoked in writing except to the extent already acted upon.

Patient Rights: You may withdraw this authorization at any time by delivering a written notice to the Provider, except to the extent the Provider has relied on this authorization to process orders or submit claims.

Acknowledgment & Certification

I certify that the information provided on this form is accurate to the best of my knowledge. I acknowledge that I have had the opportunity to ask questions about the products and services described and that my questions have been answered to my satisfaction. I accept responsibility for proper use and maintenance of the provided products and agree to notify the Provider promptly of any device malfunction or adverse event.

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