DIABETES MANAGEMENT & SUPPLIES
NOTICE OF PRIVACY PRACTICES
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.
Each time you visit or contact us by telephone, mail, fax or other means, DMS makes a record of the contact made. Typically, this record contains your symptoms, examination and test results, diagnoses and treatment, a plan for future care or treatment, and billing information. This notice applies to all of the records of your care generated by DMS, whether made by DMS personnel, agents of DMS, or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic. This Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA).
This Notice describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and controls your protected health information in some cases. Your “protected health information” means any of your written, electronic, and orally transmitted health information, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present, or future physical or mental health or condition.
We are required by law to maintain the privacy of your protected health information and provide you a description of our privacy practices. We are required to abide by the terms of this notice.
- Click here to download our HIPAA Notice of Privacy (PDF).
- Click here to download our HIPAA Acknowledgment Form (PDF).
Patient Bill of Rights
A patient's bill of rights is a list of guarantees for those receiving medical care. It may take the form of a law or a non-binding declaration. Typically a patient's bill of rights guarantees a patient's information, fair treatment, and autonomy over medical decisions, among other rights.
Patient Authorization
The Patient Authorization Form authorizes your healthcare provider to disclose your health and personal information to Diabetes Management & Supplies and its employees, representatives, and agents in connection with referral sources in accordance with the Health Insurance Portability and Accountability Act of 1996 and related federal regulations and rules (“HIPAA”).
Medicare Standards
Medicare DMEPOS Supplier Statement
DMEPOS suppliers have the option to disclose the following statement in order 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 Diabetes Management & Supplies 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 from the U.S. Government Printing Office website. Upon request, we will provide you with a written copy of the standards.
Pump Rental Agreement
DMS Blank Forms
Explore & Sign Our Forms & Documents
Our frequently used forms and documents are available for download and to be filled out and uploaded in a safe and secure environment. Get started today by checking out the forms below.
Using Our Blood Glucose Logs
- Click on the Blood Glucose Log link above to get a PDF.
- Print and write into the form or save the document to your computer and type in your results.
- After your log is complete, upload a copy of the printed log or the electronic log if you typed in your results.
- Document Upload Page