1. When accepting Medicare assignment, Northern Illinois Home Medical Supply, NFP (herein referred to as NIHMS) agrees that the charge determined by Medicare shall be the full charge for any equipment or service; and that the Customer is responsible for any deductible and 20% co-pay balances.
2. If a Medicare customer has supplemental insurance, NIHMS will submit an appropriate claim for the 20% co-insurance.  If the customer’s supplemental medical insurance carrier denies payment of the claim for any reason, or fails to pay the entire claim within sixty (60) days from the invoice date, the customer will be required to pay the outstanding balance.  If the customer fails to pay the outstanding balance within ninety (90) days from the original invoice date, NIHMS may exercise its right to proceed with collection proceedings.  Customer and/or his/her representative will be liable for any costs incident to the outstanding balances. Past due accounts will be assessed a finance charge at the periodic rate of 1½% per month which is an APR of 18%, or a periodic rate not to exceed the maximum rate allowed by state law.
3. Medicare customers are responsible for the reimbursement of the annual Medicare Part B deductible.  The Medicare law requires that this deductible be met before any claims can be paid.  The deductible is applied towards the first claim processed by Medicare for the calendar year.  If the deductible or part of the deductible is applied towards a NIHMS invoice, NIHMS will bill the customer that amount along with any co-insurance then due.
4. For customers without Medicare Part B coverage, NIHMS will make reasonable efforts to bill and collect from any/all third party sources.  In the event the customer has no third party coverage, the customer is liable for the full charges due.  In the event of non-payment for a period of more than sixty (60) days NIHMS may exercise its right to start collection proceedings including costs and attorney’s fees.  In all instances, the customer is liable for any/all amounts not reimbursed by third party carriers.  Past due accounts will be assessed a finance charge at the periodic rate of 1 ½% per month which is an APR of 18%, or a periodic rate not to exceed the maximum rate allowed by state law.
5. If the customer loans, sells, destroys or abuses the equipment, the customer agrees to pay NIHMS for the replacement value of damaged rental equipment, as well as all other charges due and owing under this agreement.  
6. Customer agrees to provide NIHMS immediately with notice of change of address, change of physician, change of physician orders, or change in medical necessity or condition.
7. DISCLAIMER OF WARRANTIES: NIHMS makes no warranty to customer hereunder.  The only warranty available to the customer is that of the manufacturer of the rental/purchase equipment. NIHMS excludes all other warranties, expressed or implied, including, but not limited to, any implied warranty of merchantability or of fitness for a particular purpose.  
8. Customers will not attempt to make any repairs or adjustments to the rental equipment.  In the event of equipment malfunction, customer agrees to contact NIHMS for repair.
9. Customer will not permit persons who have not read the operating instructions to operate the equipment.
10. NIHMS and/or the customer have the option to terminate this agreement within 30 days of written notice.
11. The term customer, wherever used in this contract, also applies to the person responsible for payment if he/she is not the actual user of the equipment.
12. Prices are subject to change upon notice to the customer.  

EQUIPMENT WARRANTY INFORMATION

Many products sold or rented by Northern Illinois Home Medical Supply carry a manufacturer’s warranty.  Northern Illinois Home Medical Supply will inform all customers of any manufacturer’s warranty coverage on the equipment that they buy or rent, and we will honor all manufacturers’ warranties expressed and implied under applicable State law.

Northern Illinois Home Medical Supply will repair or replace, free of charge, equipment that is under manufacturer’s warranty.  In addition, an owner’s manual with warranty information will be provided to beneficiaries for all durable medical equipment where this manual is available.

RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS

“I authorize and consent to the release of any information needed by Northern Illinois Home Medical Supply, NFP in the provision of services or to obtain third party billing and payments.  I request payment of authorized benefits be made on my behalf directly to Northern Illinois Home Medical Supply, NFP.  I authorize release of necessary information to any accrediting organization involved with Northern Illinois Home Medical Supply, NFP.”