Attachment 4.docx

ATTACHMENT #4 (Part 1)

PATIENT RIGHTS AND RESPONSIBILITIES DURABLE MEDICAL EQUIPMENT PROGRAM

You are eligible for VA Durable Medical Equipment. In accepting the VA’s assistance with equipment and expenses you agree to the following:

Your Rights in the VA Durable Medical Equipment Program:

1. Be given information about your rights and responsibilities for receiving VA Durable Medical Equipment.

2. Be given appropriate and quality Durable Medical Equipment without discrimination against race, color, religion, sex, national origin, sexual orientation, handicap or age.

3. Be treated with courtesy and respect by all that provide Durable Medical Equipment to you under this program.

4. Be free from physical and mental abuse and neglect.

5. Be given proper identification by name and title by everyone who provides Durable Medical Equipment to you.

6. Receive a timely response regarding any request for Durable Medical Equipment under this program.

7. Be given privacy and confidentiality.

8. Voice grievances with and / or suggest changes in the Durable Medical Equipment Program and / or staff without being threatened, restrained, or discriminated against.

9. Be given information concerning the consequences of refusing treatment.

10. Refuse treatment within the confines of the law.

ATTACHMENT #4 (Part 2)

YOUR RESPONSIBILITIES IN THE DURABLE MEDICAL EQUIPMENT PROGRAM

1. Allow Durable Medical equipment personnel in your residence for scheduled appointments/deliveries.

2. Be courteous to personnel providing the Durable Medical Equipment and keep scheduled appointments with them.

3. Provide appropriate cleared space and comply with fire and safety codes/requirements so that equipment can be set up by the Durable Medical Equipment personnel and used safely.

4. Follow Durable Medical Equipment personnel verbal and written instructions in proper, safe use and maintenance of equipment.

5. Contact your local VA Prosthetics Office in the event equipment malfunctions or requires repairs during normal business hours (see telephone #s, below).

6. Durable Medical Equipment malfunction or repair issues can normally be addressed the next business day and it is less costly, for VA to do so. However, if there is an equipment malfunction emergency that occurs after normal working hours, weekends, or holidays please contact the Contractor at _________ .