S02 - Attachment A Veteran Rights and Responsibilities.docx

Attachment A VETERAN RIGHTS & RESPONSIBILITIES (Page 1 of 2) Veteran Name: Last 4 SSN: ______ DOB: _________ VA Site_______________ As a Veteran, you have the RIGHT to:

· Be treated with appropriate, considerate, respectful and courteous care.

· Discuss with our staff your concerns or issues pertaining to the quality of services and/or DME furnished to you.

· Express your concerns regarding the timeliness of services and devices provided.

· Discuss your eligibility and entitlement to Prosthetic Services with staff personnel.

· Privacy; to refuse to take part in any research studies.

· Complete, and have placed on file, a copy of your Veteran Satisfaction Form clearly stating your questions and concerns.

· Receive a response to a written complaint in a timely manner.

· Refuse treatment/equipment and knowingly refuse to be provided care and equipment to treat your condition.

· Appeal any decision made by the Prosthetic & Sensory Aids Service concerning your eligibility and entitlement to receive such services or equipment.

As a Veteran of the Veterans Affairs Medical Center, you have the RESPONSIBILITY to:

· Treat VA and contractor employees with respect and courtesy.

· Take reasonable care when using DME issued to you.

· Exercise reasonable care and maintenance of devices and appliances issued to you.

· Immediately advise the Prosthetic &Sensory Aids Service of defective equipment.

· Advise your clinician at the VA Medical Center when equipment is no longer required for your use.

· Not sell or give away any equipment provided to you by the Department of Veterans Affairs.

· Comply with the prescribed treatment plan and communicate any concerns or health care needs with health care providers.

As a Veteran of the VA Medical Center, you have the RESPONSIBILITY to:

· Allow the DME supplier employees to make home visits on a regular basis.

· Immediately notify your local Prosthetics section at your local VA hospital of any problems with your DME equipment or if you have any health concerns.

· If urgent assistance is needed related to your condition, please go to nearest urgent care or dial 911.

I understand that my signature on this agreement authorizes any entity with medical information regarding me, to release to Company any information regarding my medical history, treatments or other relevant medical information. I understand that my signature on this agreement authorizes Company to release my Company medical records to: any authorized representative of certain local, state, or national licensing, credentialing or accrediting boards or bodies, such as The Joint Commission, certain local, state, and national entities, as well as certain public utilities, for Emergency Preparedness planning purposes.

This release specifically includes the release of my clinical records. I understand that I have the right to refuse to release my medical records, and that by signing this agreement, I waive that right. This consent is valid for whatever time-period is reasonably necessary for these authorized representatives to complete these tasks and shall remain in effect until such time as I revoke it in writing. The revocation will have a prospective application only.

VETERAN RIGHTS & RESPONSIBILITIES

(Page 2 of 2))

PROVISION OF PRODUCTS:

I understand that my signature on this agreement authorizes Company to provide the products and/or services to me. I also understand that the products and/or services provided to me by Company or its agents are provided under the direction of my physician and that Company is not liable for any act or omission when following the instructions of my physician. I will grant visits to my residence for the home oxygen supplier to perform tasks directed by the VA for oversight of my equipment, supplies and service. (Continued on Page 2)

ELECTRICAL SAFETY:

If I have been informed that my electrical outlets are not grounded, I have the option of having this condition corrected by a certified electrician, or using the equipment "as is". If I choose to use the equipment with a non- grounded outlet, the Company is not responsible for any problems associated with such use.

By signing below, I certify that I have read the foregoing, received a copy thereof, and am the Veteran, or duly authorized by the Veteran as the Veteran's general agent to execute the above, and accept its terms on behalf of the Veteran.

Veteran Signature: ________________________________________________________ Date: ____________

Employee Signature: _____________________________________________________Date: ___________ VA 1626 Client Assessment & Plan of Care - RESP (VISN 12) Rev 2/02/2021