Safespace Customer Packet

Thank you so much for your application! Your insurance requires that we educate you on the bed, its proper usage, and how to care for it. Please sign this education packet below. Once we receive this signed form, we can send a request for the paperwork we need for the prior authorization request to the patient’s physician(s).

Instructions for completion: as the caregiver for the patient, you will need to sign your name on the form -however, on the last page (checklist of paperwork provided) for: CUSTOMER NAME, please add the patient’s name in this section as they will be the person who is receiving the bed. All other areas will be your name and signature. We will request paperwork from the physician’s office once this is completed.

Welcome

Mission Statement

Patient/Client Bill of Rights

HIPAA Privacy Practice Standards

Education And Instruction Materials

Home Safety Information

Emergency Preparedness

Complaint Procedure

Medicare Supplier Standards

Medicare Capped Rental Statement

Non-Covered Equipment - ABN

Assignment of Benefits - Insurance

Information Release (Signature)

Equipment Warranty Information

Checklist of Receipt of Documents (Signature)

Welcome to Safe Place Bedding LLC

We are Jon and Amara Smith, happily married for 19 years and the proud parents of Skyler, Alara, and Abigail. We created the Safe Place Travel and Permanent Beds to solve our own sleep struggles with Skyler, who has Angelman Syndrome. For seven years, we never had a peaceful night together in our own bed - one of us always had to be with him at night. It was exhausting, and the constant sleep deprivation was hard on our relationship and our other children.

Then we discovered he slept well in enclosed spaces - finally a solution! But we looked around and found that safety beds were wildly expensive, and none of them were portable. Our first mission was to create a SAFE sleeping solution while away from home, so we created a travel bed that can be used anywhere and be ready in 5 minutes! It changed our lives, and that's when we knew we had to share our product with the world. So, we did! We took this sleeping solution miracle to the next level by creating a permanent safety bed that can be uniquely designed by our customers and offered the same great restful atmosphere as our travel beds. Now, families like ours have sleep, safety, and sanity at home and away.

Jon is a registered nurse and inventor, and Amara is a homeschooling Mama and author. We believe in chasing dreams and living without limits, and we want to help you do the same! Our mission is to give the WHOLE family the joy of making memories at home or away with a safe, stylish, affordable, and hassle-free sleeping solution for your restless, special needs loved one.

Mission Statement

At Safe Place Bedding our goal is to provide sleeping solutions for children and adults with special needs. Whether they are at home or traveling, every special needs individual deserves to have somewhere to sleep that brings them comfort and provides safety. This will not only improve the quality of life of the special needs individual, but their family as a whole.

HIPAA Patient/Client Bill of Rights

As a Customer of Safe Place Bedding:

You have the right to be notified in writing of your rights and obligations before treatment has begun.
The patient's family or guardian may exercise the patient's rights when the patient has been judged incompetent.
We fulfill our obligation to protect and promote the rights of our patients, including the following:

1. Customer Rights: As the patient/caregiver, you have the right to:

Be treated with dignity and respect.
Confidentiality of patient records and information pertaining to a patient's care.
Be presented with information at admission to participate in and make decisions concerning your plan of care and treatment.
Be notified in advance of the types of care, frequency of care, and the clinical specialty providing care.
Be notified in advance of any change in your plan of care and treatment.
Be provided with equipment and service in a timely manner.
Receive an itemized explanation of charges.
Express grievances without fear of reprisal or discrimination.
Receive respect for the treatment of one's property.
Be informed of potential reimbursement for services under Medicare, Medicaid or other third-party insurers based on the patient's condition and insurance eligibility (to the best of the company's knowledge).
Be notified of potential financial responsibility for products or services not fully reimbursed by Medicare, Medicaid or other third-party insurers (to the best of the company's knowledge).
Be notified within 30 working days of any changes in charges for which you may be liable.
Be admitted for service only if the company can provide safe, professional care at the scope and level of intensity needed; if unable to provide services, we will provide alternative resources.
Purchase inexpensive or routinely purchased durable medical equipment.
Expect that we will honor the manufacturer's warranty for equipment purchased from us.
Receive essential information in a language or method of communication that you understand.
Each patient has a right to have his or her cultural, psychosocial, spiritual, and personal values, beliefs and preferences respected.
To be free from mental, physical, sexual, and verbal abuse, neglect and exploitation.
Access, request an amendment to, and receive an accounting of disclosures regarding your health information as permitted under applicable law.

2. Customer Responsibilities: As the patient/caregiver, you are RESPONSIBLE for:

Notifying the company of change of address, phone number, or insurance status.
Notifying the company when service or equipment is no longer needed.
Notifying the company in a timely manner if extra equipment or services will be needed.
Participating as in the plan of care/treatment.
Notifying the company of any change in condition, physician orders, or physician.
Notifying the company of an incident involving equipment.
Meeting the financial obligations of your health care as promptly as possible.
Providing accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters pertinent to your health.
Your actions if you do not follow the plan of care/treatment.

3. Our Rights: As your provider of choice, we have the right to:

Terminate services to anyone who knowingly furnishes incorrect information to our company to secure durable medical equipment.
To refuse services to anyone who during direct care is threatening, intoxicated by alcohol, drugs and/or chemical substances and could potentially endanger our staff and patients.

HIPAA PATIENT PRIVACY RULE

Under the Federal HIPAA privacy rule, we are required to give you our notice of Privacy Practices and make a good faith effort, before providing services, to your Acknowledgement of Receipt of this 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.”

Safe Place Bedding LLC is committed to preserving the privacy of your personal health information. In fact, we are required by law to protect the privacy of your medical information and to provide you with this notice describing how your medical information is used and disclosed for your treatment, to obtain payment for treatment, administrative purposes and to evaluate the quality of care that you receive.

Uses and Disclosures: We use and disclose elements of your Protected Health Information (PHI) in the following ways:

Treatment: including, but not limited to, inpatient, outpatient or psychiatric care.
Your treating physician(s).
Payment: including, but not limited to, asking you about your health care plan(s), or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts, either ourselves or through a collection agency or attorney.
Health care operations: including, but not limited to, financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.
Disclosures when release is authorized by law, including, but not limited to, judicial settings and to health oversight regulatory agencies, law enforcement and correctional institutions.
Uses or disclosures for specialized government functions including, but not limited to, the protection of the President or high-ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign services.
If emergency situations or other serious health / safety situations.
If you are a member of the armed forces, we may release medical information about you and your dependents as requested by military command authorities.
Disclosures of de-identified information.
Disclosures relating to workers’ compensation claims.
To medical examiners, coroners or funeral directors to aid in identifying you or to help them in performing their duties.
To organizations that handle organ and tissue donations.
To public health authorities or federal organizations in the event of a communicable disease or to report a defective device or untoward event to a biological product (food or medication).
Disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information.
We may be required or permitted by certain laws to use and disclose your medical information for other purposes without your consent or authorization.
We will notify you by e-mail or US Mail of any breaches of your PHI.
You have the following rights concerning your protected health information (PHI):

Patient Signature:

Restrictions: To request restricted access to all or part of your PHI. To do this, contact the organization’s HIPAA Privacy and Security Officer. We are not required to grant your request, and you do not have the right to restrict disclosures required by law. If we do agree, we must honor the restrictions you request.

Confidential Communications: To receive correspondence of confidential information by alternate means or location such as phoning you at work rather than at home or mailing your health information to a different address. To do this, contact the organization’s HIPAA Privacy and Security Officer. We will take reasonable actions to accommodate your request.

Access: To inspect or receive copies of your PHI. To do this, contact the organization’s HIPAA Privacy and Security Officer. In certain circumstances you may not have the right to access your records if the organization reasonably believes (or has reason to believe) that such access would cause harm.

Examples include, but are not limited to, certain psychotherapy notes, information compiled in reasonable anticipation of or for use in civil, criminal or administrative actions or proceedings, or information obtained from someone other than a healthcare provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

Amendments / Corrections: To request changes be made to your PHI. To do this, contact the organization’s HIPAA Privacy and Security Officer. We are not required to grant your request if we did not create the record, or if the record is accurate and complete. If we deny your request for amendment/correction, we will notify you why, how you can attach a statement of disagreement to your records (which we may rebut), and how you may complain. If we agree to the request, we will make the correction within 60 days and will send the corrected information to persons we know who got the wrong information, and others you specify.

Accounting: To receive an accounting of the disclosures by us of your PHI. To do this, contact the organization’s HIPAA Privacy and Security Officer. Accounting does not include disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law, we can have a 30-day extension of time if we notify you of the extension in writing. We are not required to give you a list of disclosures that occurred before April 14, 2003.

This Notice: To get updates or reissue of this notice, at your request.

Complaints: To complain to us or the U.S. Department of Health & Human Services if you feel your privacy rights have been violated. To register a complaint with us, contact: 614-602-5196.

The law forbids us from taking retaliatory action against you if you complain.

Our Duties: We are required by law to maintain the privacy of your protected health information (PHI). We must abide by the terms of this notice or any update of this notice.

As a patient of Safe Place Bedding LLC, you have important rights relating to inspecting and copying your medical information that we maintain, amending or correcting the information, obtaining an accounting of disclosures of your medical information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated.

Education and Instruction Materials

Comprehensive instructions will be included with every product to ensure safe and effective use. Should you have any questions, concerns, or need additional support, please contact us anytime at Limitless@safeplacebedding.com or 614-602-5196.

Please click on the link below to learn more about Safe Place Bedding.

Instructions/Information on Safespace Beds

Important information to note:

Enclosed beds should not be used for discipline, or as a restraint during times of high tension, tantrums, or anger.
To limit sensory denial, enclosed beds should be used at night for sleeping and only for short rests, or naps during the day.
Tough behaviors to include self-injury may increase due to sensory denial if a child is left in an enclosed bed for extended periods of time.
A video monitor is highly recommended for safety during use at nap time or night.
Always be available to help users in and out of bed to avoid falls.
If any medical emergency happens during the night or while using the bed, call 911 or your local emergency medical services.

Email: Limitless@safeplacebedding.com

Phone: 614-602-5196

If you would like more information or have any questions, please call or email us and we can set up a Zoom meeting.

Home Safety Assessment

Before your bed is installed here are some Safety Assessments to consider:

Is the room appropriate for the use of the equipment?
Is there enough space to use the equipment in a safe manner?
Are the electrical outlets properly grounded?
Does the home have a smoke detector?
Is the home equipped with a fire extinguisher?
Are there space heaters or sources of open flame in the house?

Home Safety Information

Here are some helpful guidelines to help you keep a careful eye on your home and maintain safe habits. Correct unsafe conditions before they cause an accident. Take responsibility and keep your home safe. Medicines

Medicines

If children are in the home, store medications and poisons in childproof containers and out of reach.
All medicines should be labeled clearly and left in original containers.
Do not give or take medicines that were prescribed for other people.
When taking or giving medicines, read the label and measure doses carefully. Know the side effects of the medicines you are taking.
Throw away outdated medicines by pouring down a sink or flushing down the toilet.

Mobility Items

When using mobility items to get around such as: canes, walkers, wheelchairs, or crutches, you should use extra care to prevent slips and falls.

You have the right to be notified in writing of your rights and obligations before treatment has begun.
The patient's family or guardian may exercise the patient's rights when the patient has been judged incompetent.
We fulfill our obligation to protect and promote the rights of our patients, including the following:

Use extreme care to avoid using walkers, canes, or crutches on slippery or wet surfaces.
Always put the wheelchairs or seated walkers in the lock position when standing up or before sitting down.
Wear shoes when using these items and try to avoid obstacles in your path and soft and uneven surfaces.

Slips and Falls

Slip and falls are the most common and often the most serious accidents in the home. Here are some things you can do to prevent them in your home:

Arrange furniture to avoid an obstacle course.
Install handrails on all stairs, showers, bathtubs and toilets.
Keep the stairs clear and well lit.
Place rubber mats or grids in showers and bathtubs.
Use bath benches or shower chairs if you have muscle weakness, shortness of breath, or dizziness.
Wipe up spilled water, oil, or grease immediately.
Pick-up and keep surprises out from under foot, including electrical cords, throw rugs, or other items on the floor.
Keep drawers and cabinets closed.
Keep tubing under your control. Tubing may catch on furniture, doors, knobs, rugs, or other items on the floor.
Install good lighting to avoid gropping in the dark.

Lifting

If it is too big, too heavy, or too awkward to move alone - GET HELP. Here are some things you can do to prevent lower back pain or injury.

Stand close to the load with your feet apart for good balance.
Bend your knees and "straddle" the load.
Keep your back as straight as possible while you lift and carry the load.
Avoid twisting your body when carrying a load
Plan ahead - clear your way.

Electrical Accidents

Watch for early warning signs - e.g. overheating, a burning smell, sparks. Unplug the appliance and get it checked right away. Here are some things you can do to prevent electrical accidents.

Keep cords and electrical appliances away from water.
Do not plug cords under rugs, through doorways or near heaters. Check cords for damage before use.
Extension cords must have big enough wires for larger appliances.
If you have a broken plug, outlet, or wire, get it fixed right away.
Use a ground on 3-wire plugs to prevent shock in case of electrical "fault."
Do not overload outlets with too many plugs.
Use three-prong adapters when necessary.

Smell Gas?

Open windows and doors.
Shut off appliance involved. You may be able to refer to the front of your telephone book for instructions regarding turning off the gas to your home.
Don't use matches, light candles or turn on electrical switches.
Don't use telephone - dialing may create electrical sparks.
Call the Gas Company from a neighbor's home.
If your gas company offers free annual inspections, take advantage of them.

Fire

Pre-plan and practice your fire escape. Prepare a plan with at least two ways out of your home. If your fire exit is through a window, make sure it opens easily. If you are in an apartment, know where the exit stairs are located. Do not use the elevator in a fire emergency. You may notify the fire department ahead of time if you have a disability or special needs. Here are some steps to prevent fires:

Install smoke detectors. They are your best early warning. Test frequently and change the battery every year.
Throw away old newspapers, magazines and boxes.
Empty waste baskets and trashcans regularly.
When there is oxygen in use, place a "No Smoking" sign in plain view of all people entering the home and do not permit anyone to smoke near the patient
Do not allow ashtrays or used matches to be tossed into wastebaskets unless you know they are out. Wet down first or dump into toilet.
Have your chimney and fireplace checked frequently. Look for and repair cracks and loose mortar. Keep paper, wood, and rugs away from area where sparks could hit them.
Be careful when using space heaters.
Follow instructions when using a heating pad to avoid serious burns.
Check your furnace and pipes regularly. If nearby walls or ceilings feel hot, add insulation.
Keep a fire extinguisher in your home and know how to use it.

If you have a fire or suspect fire

Take immediate action per plan - escape is your top priority.
Get help on the way - with no delay. CALL 9-1-1.
If your fire escape is cut off, close the door and seal the cracks to hold back smoke.
Signal help from the window.

Emergency Preparedness

Safe Place Bedding LLC has a comprehensive emergency preparedness plan in case a disaster occurs. Disasters may include fire to our facility, chemical spills in the community, hurricanes, tornadoes and community evacuations. Our primary goal is to continue to service your health care needs. It is your responsibility to contact us regarding any supplies you may require when there is a threat of disaster or inclement weather so that you have enough supplies to sustain you.

If a disaster occurs, follow instructions from the civil authorities in your area. We will utilize every resource available to continue to service you. However, there may be circumstances where we cannot meet your needs due to the scope of the disaster. In that case, you must utilize the resources of your local rescue or medical facility. We will work closely with the authorities to ensure your safety.

Complaint Procedure

Safe Place Bedding LLC provides a process for clients to lodge an oral, written, or telephone complaint about the products and services provided. Safe Place Bedding LLC has a complaint resolution system for identifying, responding to, and resolving complaints in a timely manner.

All written, oral, and name of client or caregiver voicing the complaint.

A summary of the complaint, including:

Date received
Name of the person receiving the complaint
A summary of actions taken to resolve the complaint
If an investigation is not conducted, the name of the person who made that decision, along with the reason for not investigating
Signature of supervisor

All employees are trained in how to handle complaints. Copies of all complaints and investigations are kept on-file for at least three years. All complaints are summarized and presented to Executive Management quarterly.

If you have a complaint, please contact us at: 614-602-5196. Additionally, you may contact Centers for Medicare and Medicaid Services (CMS) at 1-800-MEDICARE, if needed. You may also contact our accreditation provider if needed. Our accreditation provider is HQAA and can be reached at 866-909-4722.

Medicare DMEPOS Supplier Standards

DMEPOS suppliers have the option to disclose the following statement to satisfy the requirement outlined in Supplier Standard 16 in lieu of providing a copy of the standards to the beneficiary.

The products and/or services provided to you by Organization name are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained at http://www.ecfr.gov. Upon request, we will furnish you with a written copy of the standards.

Medicare Capped Rental and Inexpensive or Routinely Purchased Items Notification

Patients with Medicare benefits may either rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental durable medical equipment, as defined in § 414.220(a) of this subchapter. At this time Safe Place Bedding does not offer any rental products in our catalog.

Non-Covered Equipment - ABN

Please be aware that some equipment you receive may not be covered by Medicare or other insurers. We will provide you with an advance beneficiary notice (ABN) for any services that Medicare or other insurers will not cover cover prior to providing the equipment to you. Such non-covered equipment will require your prior approval before they are provided. You are responsible for payment at the time the equipment is provided..

Assignment of Benefits - Insurance

To properly bill your insurance company, we require that you disclose ALL insurance information including primary and secondary insurance, as well as any change of insurance information. I request that payment of authorized Safe Place Bedding benefits be made on my behalf to Safe Place Bedding for any products and supplies provided to me by Safe Place Bedding. I authorize Safe Place Bedding to release any medical information about me to my insurance company(s) and its agents that are needed to determine those benefits or the benefits payable for related items and services.

Authorization for Safe Place Bedding to Submit Claims on My Behalf

I authorize Safe Place Bedding to submit insurance claims on my behalf for payment to Safe Place Bedding for items and services provided to me. I consent to the release of all protected health information by my physician and other health care providers required by Safe Place Bedding and its agents for the purposes of healthcare management and/or processing of medical claims.

My Payment and Notification Responsibilities

I agree that I am responsible for any deductible, coinsurance payment, and potentially other amounts not covered by Safe Place Bedding or by any other insurance, except as otherwise prohibited by law. I agree that I will notify Safe Place Bedding immediately of any changes in my insurance coverage or insurance provider(s). If your insurance company should happen to send payment to you, the patient, we expect that you would forward it to our office to be applied to your balance.

Medicare Patients - Assignment of Benefits

I request that payment of authorized Medicare benefits be made to me or on my behalf to Safe Place Bedding LLC for durable medical equipment and supplies ordered by my physician. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. I understand that my signature requests that payment be made and authorizes the release of medical information necessary to pay the claim.

If there is no signature on file, or if electronic or signed authorization forms have been approved elsewhere on the approved claim form or electronically submitted claims, my signature authorizes releasing the information to the insurer or agents listed. In Medicare assigned cases, the supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered items. Coinsurance and the deductible are based upon the charge determination to the Medicare carrier.

Providing Correct Information and Information Release

I certify that the information I furnish is true and correct. I know it is a crime to fill out this form with facts that I know are false or to leave out facts that are important. I hereby authorize Safe Place Bedding, LLC to submit a claim to my insurance carrier or its intermediaries for all covered prescriptions or durable medical equipment and authorize and direct my insurance carrier or its intermediaries to issue payment directly to Safe Place Bedding, LLC.

I hereby authorize Safe Place Bedding, LLC to furnish complete information requested by my insurance carrier or its intermediaries regarding services rendered. I further agree that I am responsible for paying my co-pays or balances which remain after insurance payments have been made, including any cost of collection or legal fee incurred to collect these balances.

Patient Signature:(Required)

Date:(Required)

If someone other than the patient has signed, please type name, relationship, and reason patient was unable to sign.

First Name:(Required)

Last Name:(Required)

Relationship to Patient:(Required)

Reason patient unable to sign:(Required)

Minor Child

Other

Equipment Warranty Information

Adaptive Imports is the US distributor of many high-quality products from various manufactures. A 1- year warranty against defects in workmanship and materials is extended to all items sold by Adaptive Imports in the USA. Warranty is provided and honored through the network of registered dealers who purchase, and supply products distributed by Adaptive Imports. The warranty does not cover accidental damage, including damage caused by misuse or neglect. This warranty does not extend to non-durable parts, which are subject to normal wear and tear and need periodic replacement. The warranty is null and void if non-original manufacture parts/accessories are used, or if the product is repaired or altered by anyone other than an authorized Adaptive Imports dealer.

Incontinence Pads and Positioning pillows are covered by a one year warranty against manufacture defects.

Medline Products carry a 1-3 year manufacture warranty against Manufacture defects.

Checklist of Paperwork Provided

Customer Name(Required)

Date(Required)

ltem(s) received: See Invoice

Welcome Packet

Product Education and Instruction Materials

Patient Rights and Responsibilities

HIPAA Privacy Practice Standards

Warranty Information

Hours of Operation, Phone number and how to obtain Service

Cost of Equipment/Supplies Provided