PROMEDICAL EAST LLC OR ITS AFFILIATES E&D HOLDINGS LLC, SIMON MEDICAL SERVICES
Customer Information Handout
Welcome! Thank you for choosing PROMEDICAL EAST LLC OR ITS AFFILIATES E&D HOLDINGS LLC, SIMON
MEDICAL SERVICES to be your medical equipment supplier. This handout provides you with information for
your overall health care. Please keep this handout for reference and call our office at anytime if you have
questions. In specific, this handout shares information with you about the following: Our commitment in
providing quality services and products, Our grievance procedure, Patient communication form, Your rights
and responsibilities as a customer, Medicare supplier standards, Our service, delivery and warranty policies,
Our billing and payment policies/Assignment of Benefits, Notice of privacy practices. We are dedicated to
providing comprehensive home care services to our customers with the utmost quality and professionalism.
We accept only those customers whose home health needs, as identified by the referring source, can be met
by the services we offer. We not only provide quality home care products, we genuinely care for the customers
we serve. Our services include the following: Customer instruction and training on all products provided;
Experienced clinical, and office staff to assist you. At the end of this handout you will be asked to acknowledge
that you received this handout and that you have read and understand the information we have provided to
you. SCOPE OF SERVICES: DIABETIC TESTING SUPPLIES, METERS, LANCETS, TEST STRIPS, CONTROL SOLUTION, LANCET DEVICES,
AND BATTERIES. DIABETIC SHOES: DR. COMFORT SHOES, APEX SHOES, HEAT AND CUSTOM MOLDED INSERTS. SPECIALTY ITEMS:
ORTHOPEDIC BRACING AND SUPPORTS. Geographic Coverage: GEOGRAPHIC COVERAGE AREAS: Continental United
States Mission Statement: To be the leading provider of home health and institutional products by
demonstrating our commitment to clinical excellence, customer service and by delivering specialty services
ensuring quality care for all patients and being a reliable partner to the health care community. Compliance
and Commitment: ProMedical East LLC or its affiliates E&D Holdings LLC, Simon Medical Services is committed
to complying with all federal and state regulations. If you have any questions or concerns regarding any of our
activities, please contact you service location at the telephone number on the front of this handout. Patient
Grievance Procedure: All of our customers are very important to us. So that we can resolve any problems that
arise in a rapid and effective manner, we have developed the following patient grievance procedure. 1 When
you have a concern, you can speak to the representative delivering your equipment at the next visit. 2. If you
do not want to wait to speak to the representative person or if the issue you have involves our representative,
you can call our office and speak with the manager of your servicing location. 3. If your issue cannot be solved
locally you may contact the company at the number on the cover of this handout. Patient Rights: As a patient/
client and/or designate of our company, you have rights, which include, but are not limited to the following:
1.Be given information about your rights for receiving homecare services.2.Receive a timely response from our
company regarding your request for homecare services.3.Be given information about our company polices,
procedures, and charges for services. This should cover billing/reimbursement methodologies including fees
for services/products. 4. Freely choose your homecare provider(s). 5. Be given appropriate and professional
quality homecare services without discrimination in regards to your race, color, creed, religion, sex, national
origin, sexual orientation, handicap or age. 6. Be treated with courtesy and respect by all who provide
homecare services to you. 7. Be free from physical and mental abuse and/or neglect. 8. Be given proper
identification by name and title of everyone who provides homecare services to you. 9. Be given the necessary
information regarding treatment and choices concerning rental or purchase options for durable medical
equipment so you will be able to give informed consent for service prior to the start of any service. 10. A plan
of care/service that will be developed to meet your unique service needs. 11. Be afforded privacy and
confidentiality of medical condition, medical records, and billing records. 12. Voice grievance with and/or
suggest change in homecare serviced and/or staff without being threatened, restrained, and discriminated
against. 13. View your records. 14. File a complaint with ACHC hot line at (855) 937-2242, hours 9:00-5:00 PM
EST. 15.File a complaint with the Pennsylvania Bureau of Consumer Protection at (800) 441-2555. Patient
Pro Medical East LLC – 1413 Stenton Avenue, Philadelphia, PA 19141- 1995 Rutgers University Blvd, Lakewood NJ 08701 – 888-200-2797
Responsibilities: As a patient/client you also have certain responsibilities. These responsibilities include the
following: 1. Give accurate and complete health information concerning your past illnesses, hospitalization,
medications, allergies, and other pertinent items. 2. Assist in developing and maintaining a safe environment
within your home. 3. Inform our company when you will not be able to keep a homecare visit. 4. Participate in
the development and update of you homecare plan of service/treatment. 5. Adhere to your developed/
updated homecare plan of service/treatment. 6. Request further information concerning anything you do not
understand. 7. Contact your doctor whenever you notice any change in your condition. 8. Contact our
company whenever your insurance company or plan changes. 9. Contact our company whenever you have an
equipment problem. 10. Contact our company whenever you have received a change in your homecare
prescriptions. 11. Contact our company whenever you are to be hospitalized. 12. Contact our company prior to
any change of address. 13. Contact our company if you acquire an infectious disease during the time you are
receiving services and/or care of our company, except where exempted by law. 14. Not to attempt to repair or
modify equipment. SUPPLIER AGREEMENT: ProMedical East LLC or its affiliates E&D Holdings LLC, Simon
Medical Services agrees to be the client’s supplier for home medical equipment and supplies and to receive
payment from Medicare and other insurance companies on an assignment-related basis. ProMedical East LLC
or its affiliates E&D Holdings LLC, Simon Medical Services also agrees to bill insurance carriers for supplies and
equipment furnished to client by ProMedical East LLC or its affiliates E&D Holdings LLC, Simon Medical
Services. SUPPLIER STANDARDS: 1. The supplies and equipment are reasonable and necessary for that patient.
2. A supplier must be in compliance with all applicable Federal and State licensure and regulatory
requirements. 3. A supplier must provide complete and accurate information on the DMEPOS supplier
application. Any changes to this information must be reported to the National Supplier Clearinghouse within
30 days.4. An authorized individual (one whose signature is binding) must sign the application for billing
privileges. 5. A supplier must fill orders from its own inventory, or must contract with other companies for the
purchase of items necessary to fill the order. A supplier must provide copies of the contract upon request,
showing compliance with this standard. A supplier may not contract with any entity that is currently excluded
from the Medicare program, any State health care programs, or from any other Federal procurement or non-
procurement programs. 6. A supplier must advise beneficiaries that they may rent or purchase inexpensive or
routinely purchased durable medical equipment, and of the purchase option for capped rental equipment. The
supplier must document that it has provided beneficiaries with this information. 7. A supplier must notify
beneficiaries of warranty coverage and honor all warranties, express or implied, under applicable State law,
and repair or replace free of charge Medicare covered items that are under warranty. The supplier must
provide, upon request, documentation that it has provided beneficiaries with information about Medicare
covered items covered under warranty. 8. A supplier must maintain a physical facility on an appropriate site,
which must contain space for storing business records.9. A supplier must permit HCFA, or its agents to conduct
on-site inspections to ascertain the supplier’s compliance with these standards. The supplier location must be
accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted
hours of operation. 10. A supplier must maintain a primary business telephone listed under the name of the
business in a local directory or a toll free number available through directory assistance. The exclusive use of a
beeper number, answering machine, earphone, facsimile machine, or cell phone as the primary business
number is prohibited. 11. A supplier must have comprehensive liability insurance in the amount of at least
$300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If
the supplier manufactures its own items, this insurance must also cover product liability and completed
operations. Failure to maintain the required insurance at all times will result in revocation of the supplier’s
billing privileges retroactive to the date the insurance lapsed.12. A supplier must agree not to initiate
telephone contact with beneficiaries, unless the beneficiary has provided the supplier with written permission
to contract them by telephone, or the supplier has furnished a Medicare covered item and the supplier is
contacting the individual to coordinate delivery of the item, or if the contact involves a covered item other
than the one already supplied, then the supplier has furnished at least one covered item within the last 15
Pro Medical East LLC – 1413 Stenton Avenue, Philadelphia, PA 19141- 1995 Rutgers University Blvd, Lakewood NJ 08701 – 888-200-2797
months.13. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered
items and maintain proof of delivery. The supplier must document that such instruction has been given.14. A
supplier must answer questions and respond to complaints of beneficiaries. The supplier must refer
beneficiaries with Medicare questions to the appropriate carrier. The supplier must maintain documentation of
all such contacts with beneficiaries. 15. A supplier must maintain and replace at no charge or repair directly, or
through a service contract with another company, Medicare-covered items it has rented to beneficiaries. The
item must function as required after being repaired or replaced. 16. A supplier must accept returns of
substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary
at the time it was fitted and rented or sold) from beneficiaries. 17. A supplier must disclose these supplier
standards to each beneficiary to whom it supplies a Medicare-covered item.18. A supplier must disclose to the
government any person having ownership, financial, or control interest in the supplier. 19. A supplier must not
convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare
billing number. 20. A supplier must have a complaint resolution protocol established to address beneficiary
complaints that relate to these standards. A record of these complaints, including related correspondence and
notes of actions, must be maintained at the physical facility. 21. Complaint records must include: the name,
address, telephone number and health insurance claim number of the beneficiary, a summary of the
complaint, the date it was received, the name of the person receiving the complaint, and a summary of any
actions taken to resolve it. If an investigation was not conducted, the record should include the name of the
person making the decision and the reasons for the decision. 22. A supplier must agree to furnish HCFA any
information required by the Medicare statute and implementing regulations. 23. All DMEPOS suppliers must
notify their accreditation organization when a new DMEPOS location is opened. The accreditation organization
may accredit the supplier location for three months after it is operational without requiring a new site visit. 24.
A DMEPOS supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards
and be separately accredited in order to bill Medicare. An Accredited supplier may be denied enrollment or
their enrolment may be revoked, if CMS determines that they are not in compliance with the DMEPOS quality
standards. 25. All DMEPOS suppliers must disclose upon enrollment all products and services, including the
addition of new product lines for which they are seeking accreditation. If a new product line added after
enrollment, the DMEPOS supplier will be responsible for notifying the accrediting body of the new product so
that the DMEPOS supplier can be re-surveyed and accredited for these new products. 26. Must meet the
surety bond requirements specified in 42 C.F.R. 242.57 (C). Implementation date – October 2009. 27. A
supplier must obtain oxygen from a state-licensed oxygen supplier. 28. A Supplier must maintain ordering and
referring documentation consistent with provisions found in 42 C.F.R. 424.516(f). 29. DMEPOS suppliers are
prohibited from sharing a practice location with certain other Medicare providers and suppliers. 30. DMEPOS
suppliers must remain open to the public for a minimum of 39 hours per week with certain exceptions.
Pennsylvania Residents: To report abusive, neglectful or exploitative practices clients may call the Medicare
Hotline Number 800-633-4227.NOTE: Please contact our office with any further questions about your rights
under Medicare regulations. Service, Delivery and Warranty Business Hours: Our hours of operation are 9:00
A.M. to 5:00 P.M. Monday-Friday. Delivery: Deliveries are provided by our field representatives on an
appointment basis only. Purchased Equipment and Warranties: New equipment is subject to the
manufacturer’s warranty. Refer to the warranty information provided to you at the time of purchase. All
warranties will be honored under applicable state laws. Service and Repair: Service or repair on equipment
purchased from our company is covered by the manufacturer’s warranty.. The customer will be informed of
their responsibilities regarding the ongoing care and service of the equipment and will be provided with
maintenance instructions and how to obtain any service required. All service and repair must be scheduled by
calling the office during regular business hours. Financial Policy: All patients going on account require prior
verification of insurance coverage before product is delivered. If this is not possible due to a weekend or other
after-hours delivery, verification must be done on the next business day. We do not guarantee coverage of or
payment of insurance claims. We do not guarantee any time frame for processing of insurance claims or
Pro Medical East LLC – 1413 Stenton Avenue, Philadelphia, PA 19141- 1995 Rutgers University Blvd, Lakewood NJ 08701 – 888-200-2797
subsequent billing from our office. It will be done in as timely manner as possible. Insurance Coverage:
Customer’s Responsibility: Provide us with all insurance information necessary to file your claim. Notify our
office of any changes or loss of insurance coverage. Pay all deductible and balance remaining after secondary
insurance is filed. The customer is responsible for payment in full of all claims not covered by insurance. You
will be informed before delivery if we know that an item is not covered and assignment will no be accepted.
Any arrangements or agreement for payment other than those described above must have approval from the
location manager. Special terms and approval signature must be documented on original paperwork. Medicare
Claims: Durable medical is covered under your Medicare Part B benefit. If Medicare is your insurance carrier
and denies payment, you will be notified. At that time, if you wish to keep the equipment it will be billed
directly to you. In most cases, if you have supplemental insurance, the deductible amount and the 20% are
paid by other insurance. We will follow through with the appeal process on Medicare claims that are denied.
However, this will only be done on non-assigned claims at the customer’s request. The customer is also advised
that: Inexpensive, routinely purchased durable medical equipment may be purchased. All claims, assigned or
non-assigned, will be filed on behalf of the patient. Billing and Payment Policy: Customers are responsible for
payment in accordance with our company’s terms. Assignment of benefits to a third party does not relieve the
customer of the obligation to ensure full payment. Billing third party payers is not an obligation, but rather a
service we offer if all necessary billing information and signatures are provided. Medicare: We may accept
Medicare Part B assignment, billing Medicare directly for 80% of allowed charges and billing the beneficiary
the 20% payment and any deductible. We offer Electronic Claims Transmission for billing non-assigned orders.
Presentation of your Health Insurance Card is necessary. Medicaid: We may provide equipment to Medicaid
recipient upon verification and approval of
coverage status and medical justification. Presentation of your State Beneficiaries Identification Card and
personal ID are required. Private Insurance: We may bill private insurance carriers upon verification and
approval of coverage status and medical justification. You are responsible for providing our billing department
with all necessary insurance information. You are also responsible for notifying of us any insurance changes.
Presentation of your insurance card and personal ID are required. Remember, billing a third party insurance
does not guarantee payment. Financial responsibility remains with you, the patient. Notice of Privacy
Practices: You have the following rights regarding medical information we maintain about you: Right to Inspect
and Copy. You have the right to inspect, request a summary and obtain a copy of your medical information
about you or your care. To inspect and obtain a copy of medical information about you or your care, you must
submit your requests in writing to the following location: ProMedical East LLC or its affiliates E&D Holdings
LLC, Simon Medical Services 1995 Rutgers University Blvd Lakewood, NJ 08701. If you request a copy of
information, we may charge a reasonable fee for the costs of copying, mailing and preparing an explanation or
summary of the medical information associate with your request. We may deny your request to inspect and
obtain a copy in certain very limited circumstances. If you are denied access to medical information, you may
request that the denial be reviewed. Another licensed health care professional chosen by us will review your
request. We will comply with the outcome of the review. Right to Amend. If you feel that medical information
we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right
request an amendment for as long as the information is kept by or for us. To request an amendment, your
request must be made in writing and submitted to the following location: ProMedical East or its affiliates E&D
Holdings LLC, Simon Medical Services 1995 Rutgers University Blvd Lakewood, NJ 08701. In addition, you
must provide a reason that supports your request. We may deny your request for an amendment if it is not in
writing or does not include a reason to support the request. We may also deny your request if you ask us to
amend information that: Was not created by us, unless the person or entity that created the information is no
Pro Medical East LLC – 1413 Stenton Avenue, Philadelphia, PA 19141- 1995 Rutgers University Blvd, Lakewood NJ 08701 – 888-200-2797
longer available to make the amendment. Is not part of the medical information kept by us. Is not part of the
information which you would be permitted to inspect and copy. Is accurate and complete. Right to an
Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This accounting is a list
of the disclosures we made of medical information about you. This list will include disclosures made for
treatment, payment of Advacare Systems health care operations, disclosures that you have previously
authorized us to make or other disclosures specifically exempted for the disclosure accounting by the federal.
To request this list or accounting of disclosures, you must submit your request in writing to the following
location: ProMedical East or its affiliates E&D Holdings LLC, Simon Medical Services 1995 Rutgers University
Blvd Lakewood, NJ 08701. Your request must state a time period, which may not be longer than six years and
may not include dates before August 2004. Your request should indicate in what form you want the list, such as
paper or electronically. The first list you request within a 12-month period will be free. For additional lists, we
may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose
to withdraw or modify your request at the time before any costs are incurred. Right to Request Restrictions.
You have the right to request a restriction or limitation on the medical information we use or disclose about
you for treatment, payment or health care operations. You also have the right to request a limit on the medical
information we disclose about you to someone who is involved in your care or the payment of your care, like a
family member or friend. We are not required to agree to your request. If we do agree, we will comply with
your request unless the information is needed to provide your emergency treatment. To request restrictions,
you must make you request to writing to the following location: ProMedical East or its affiliates E&D Holdings
LLC, Simon Medical Services 1995 Rutgers University Blvd Lakewood, NJ 08701 In your request, you must tell
us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; (3) to
whom you want the limits to apply, for example, disclosures to your spouse. Right to Request Confidential
Communications. You have the right to request that we communicate with you about medical matters in a
certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To
request confidential communications, you must make your request in writing to: ProMedical East or its
affiliates E&D Holdings LLC, Simon Medical Services 1995 Rutgers University Blvd Lakewood, NJ 08701. We
will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must
specify how or where you wish to be contacted. Right to a Paper Copy of this Notice. You have the right to a
paper copy of this notice. You must ask us to give you a copy of this notice at any time. Even if you have agreed
to receive this notice electronically, you are still entitled to receive a paper copy if this notice. To obtain a paper
copy of this notice, submit a request in writing to the following locations: ProMedical East or its affiliates E&D
Holdings LLC, Simon Medical Services 1995 Rutgers University Blvd Lakewood, NJ 08701. How We May Use
and Disclose Medical Information About You: The following categories describe different ways that we are
permitted to use and disclose medical information as a health provider, although certain of these categories
may not apply to our business and we may not actually use or disclose your medical information for such
purposes. For each category of uses or disclosures, we will explain what we mean and try to give some
examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted or
required to use and disclose information will fall within one of these categories. For Treatment. We may use
medical information about you to provide you with medical treatment or services. We may disclose medical
information about you to your physician, home health agency, and/or respiratory therapist who are involved in
taking care of you. For example, telephone contact for medication refills, mail contact for billing and collection
purposes, etc. We may also disclose medical information about you to people who may be involved in your
medical care after you have received our products and services, such as family members, clergy or others we
use to provide services that are part of your care. For Payment. We may use and disclose medical information
about you so that the treatment services we provide you may be billed to you and payment be collected from
you, an insurance company or a third party. For example, we may need to give your health plan information
about products and services we provided to you so your health plan will pay us or reimburse you for the
products and services. We may also tell your health plan about a treatment you are going to receive to obtain
Pro Medical East LLC – 1413 Stenton Avenue, Philadelphia, PA 19141- 1995 Rutgers University Blvd, Lakewood NJ 08701 – 888-200-2797
prior approval or to determine whether your plan will cover the treatment. For Health Care Operations. We
may use and disclose medical information about you for our health care operations. These uses and
disclosures are necessary to run our company and make sure that all of our patients receive quality care. For
example, we may use medical information to review our treatment and services and to evaluate the
performance of our staff in caring for you. We may also combine medical information about many patients to
decide what additional services we should offer, what services are not needed, and whether certain new
treatments are effective. We may also disclose information for review and learning purposes. We may remove
information that identifies you from this set of medical information so others may use it to study health care
and health care delivery without learning who the specific patients are. Delivery Reminders. We may use and
disclose medical information to contact you as a reminder that you have an appointment for treatment or
services. Treatment Alternatives. We may use and disclose medical information to tell you about or
recommend possible treatment options or alternatives that may be of interest to you. Health-Related Benefits
and Services. We may use and disclose medical information to tell you about health-related benefits or
services that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care. We may
release medical information about you to a friend or family member who is involved in your medical care or
payment for such care. We may also notify your family member, personal representative or another person
responsible for your medical care regarding your location, general condition or death. In addition, we may
disclose medical information about you to any entity assisting in a disaster relief effort so that your family can
be notified about your condition, status and location. Research. Under certain circumstances, we may use and
disclose medical information about you for research purposes. For example, a research project may involve
comparing the health and recovery of all patients who received one product or service to those who received
another, for the same condition. All research projects, however, are subject to a special approval process. This
process evaluates a proposed research and its use of medical information, trying to balance the research needs
with the patients’ need for privacy of their medical information. Before we use or disclose medical information
for research, the project will have been approved through this research approval process. We will almost
always ask for your specific authorization if the researcher will have access to your name, address or other
information that reveals who you are, or will be involved in your care. As Required By Law. We will disclose
medical information about you when required to do so by federal, state or local law. To Avert a Serious Threat
to Healthy or Safety. We may use and disclose medical information about you when necessary to prevent a
serious threat to your health and safety of the public or another person. Any disclosure, however, would only
be someone able to help prevent the threat. Special Situations: Military and Veterans. If you are a member of
the armed forces, we may release medical information about you as required by military command authorities.
We may also release medical information about foreign military personnel to the appropriate foreign military
authority. Worker’s Compensation. We may release medical information about you for worker’s compensation
or similar programs. These programs provide benefits for work-related injuries or illness. Public Health
Activities. We may disclose medical information about you for your public health activities. These activities
generally include the following. To prevent or control disease, injury or disability. To report births and deaths.
To report child abuse or neglect. To report reaction to medications or problems with products. To notify people
of recalls of products they may be using. To notify a person who may have been exposed to a disease or may
be at risk for contracting or spreading a disease or condition. To notify the appropriate government authority if
we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this
disclosure if you agree or when required or authorized by law. Health Oversight Activities. We may disclose
medical information to a health oversight agency for activities authorized by law. These oversight activities
include audits, investigations, and licensure. These activities are necessary for the government to monitor the
health care system, government programs, and compliance with civil rights laws. Judicial and Administrative
Proceedings. If you are involved in a lawsuit or dispute, we may disclose medical information about you in
response to a court or administrative order. We may also disclose medical information about you in response
to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if
Pro Medical East LLC – 1413 Stenton Avenue, Philadelphia, PA 19141- 1995 Rutgers University Blvd, Lakewood NJ 08701 – 888-200-2797
efforts have been made to tell you about the request or to obtain an order protecting the information
requested. Law Enforcement. We may release medical information if asked to do so by a law enforcement
official: In response to a court order, subpoena, warrant, summons or similar process. To identify or locate a
suspect, fugitive, material witness, or missing person. About the victim of a crime under certain circumstances.
About a death we believe may be the result of criminal conduct. About criminal conduct occurring on our
premises. In emergency circumstances to report a crime, the location of the crime or victims, or the identity,
description or location of the person who committed the crime. Coroners, Medical Examiners and Funeral
Directors. We may release information to a coroner or medical examiner. This may be necessary to identify a
deceased person or determine the cause of death. We may also release medical information about our
patients to funeral directors as necessary to carry out their duties. National Security and Intelligence
Activities. We may release medical information about you to authorized federal officials for intelligence,
counterintelligence and other national security activities authorized by law. Protective Services for the
President and Others. We may release medical information about you to authorized federal officials so they
may provide protection to the President, other authorized persons or foreign heads of state or conduct special
investigations. Inmates. If you are an inmate of a correctional institution or under the custody of a law
enforcement official, we may release medical information about you to the correctional institution or law
enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2)
to protect your health and safety or the health and safety of others, or (3) for the safety and security of the
correctional institution. Sale of Business Assets. We reserve the right to transfer medical information about
you to a third party in conjunction with the sale of our company or certain assets belonging to our company.
Changes to This Notice: We reserve the right to change this notice at any time. We reserve the right to make
the revised or change notice effective for medical information we already have about you as well as any
information we receive in the future. Complaints: If you believe your privacy rights have been violated, you
may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a
complaint with us, write to the following locations: ProMedical East or its affiliates E&D Holdings LLC, Simon
Medical Services 1995 Rutgers University Blvd Lakewood, NJ 08701. All complaints must be submitted in
writing. You will not be penalized for filing a complaint. Other Uses of Medical Information: Other uses of
medical information not covered by this notice or the laws that apply to us will be made only with you written
authorization. If you provide us authorization to use or disclose medical information about you, you may
revoke the authorization, in writing, at any time. If you revoke the authorization, we will no longer use or
disclose medical information about you for the reasons covered by your written authorization. You understand
that we are unable to take back any disclosures w have already made with your authorization, and that we are
required to retain our records of the care that we provided to you. In Case of Disaster: We are pleased to
inform you that in the event of a natural disaster, inclement weather, and/or other emergency event,
ProMedical East LLC or its affiliates E&D Holdings LLC, Simon Medical Services will continue to service you with
the help of our vendors located throughout the United States. Every attempt will be made to assure that all
shipments will continue to be mailed out in a timely fashion. If for any reason you are unable to contact our office in Pennsylvania, during normal business hours
at 1-888-200-2797, please try calling our emergency line at 484-343-2585. Medicare Hotline Number: 800-633-4227 ACHC: 855-937-2242 PA Bureau of Consumer Protection: 800-441-2555
Pro Medical East LLC – 1413 Stenton Avenue, Philadelphia, PA 19141- 1995 Rutgers University Blvd, Lakewood NJ 08701 – 888-200-2797