Intake Forms

Important Paperwork

It is important for you to sign some forms and send them back to us when you begin your services. The Consent/Assignment of Benefits form is the document that allows your insurance company to reimburse us. 

Under the federal HIPAA privacy rule we are required to give you notice of our privacy practices. The Notice of Privacy Acknowledgement is your agreement that we have provided you with this information. We also provide you with a Patient’s Bill of Rights and Responsibilities. 

We will also include printed information about your medication. If you ever need to speak with a pharmacist about medications, or a nurse about procedures, please do not hesitate to call us. 

If for any reason your service is not exceptional, we encourage you to communicate that to us so we can remedy the problem. Please see the page with our contact information to reach Ashley Kramer for grievances, or one of the pharmacists. Additionally, we are accredited by the Accreditation Commission for Healthcare (ACHC) and if grievances are not resolved to your satisfaction, you may report this to them at 919 785-3011. You may also report unexpected serious adverse reactions, product quality problems, therapeutic failure and product use errors to the FDA at 1-888-463-6332. 

Copies of these forms are included in this packet. Please read it carefully. You must also return the signed Acknowledgment Form to our physical address or email: orders@infuserveamerica.com. It is critical that we receive it as soon as possible.

It is very important we receive this form as soon as possible!

Assignment of Benefits Information Form/Notice of Privacy Information and Patient Bill of Rights

If you would like to fax this form to us instead Click Here for a printable version. You can fax the completed form to: 800-886-9229

Consent/Assignment of Benefits

1. I wish to purchase health care products/medications and/or services from Infuserve America, Inc., a privately owned home infusion therapy company.
2. I attest that my home is suitable for home infusion therapy as I have running water, refrigeration, electricity and telephone.
3. I understand that my physician is solely responsible for diagnosing and prescribing drugs and therapy for my condition and otherwise supervising and controlling my medical care. I also understand that Infuserve America, Inc., services do not include diagnostic, prescriptive or other functions typically performed by a licensed physician.
4. I agree to hold Infuserve America, its employees, representatives, volunteers, team members and agents free from all liability, claim, loss, damage or expense of any kind that may arise out of or is in any way connected to my participation in this service, including any claims based on negligence, action or inaction of any of the above parties. To the fullest extent permitted by law, I further agree to indemnify, defend, and hold harmless Infuserve America, Inc., its officers, employees, representatives, and agents from any claims, damages, or expenses arising from my failure to comply with this agreement.
5. I hereby authorize my healthcare providers to furnish to an agent of Infuserve America, Inc. any records pertaining to my medical history, services, or treatment, as needed. I further authorize Infuserve America, Inc. to release any medical information to other parties or health agencies involved in my care, or any regulatory or accrediting bodies that may be surveying Infuserve America, Inc.
6. I hereby authorize Infuserve America, Inc. to furnish my insurance carrier(s) or its agent(s) any medical information concerning my medical history, services rendered or treatments, as needed to process claims. I understand that Infuserve America does not guarantee that my insurance will pay for my services, but they will bill my insurance company as a courtesy to me. I authorize Infuserve America, Inc. to coordinate benefits among all of my insurance carriers.
7. I assign and transfer to Infuserve America, Inc. all rights to receive any insurance benefits otherwise payable to me for products or services provided by Infuserve America, Inc. I authorize my insurance company(ies) to furnish to any agent of Infuserve America, Inc. any and all information pertaining to my insurance benefits and status of claims submitted by Infuserve America, Inc. I understand I must sign the acknowledgement form, which allows my insurance company to make payments directly to Infuserve America.
8. Insurance payments are normally made within 30-60 days from time of billing. If my insurance company has not made payment within 60 days, Infuserve America will not take further action unless I specifically request it. I understand that if my insurance company rescinds, denies, or reverses payment for any reason, I remain personally responsible for the balance.
9. In the event that any insurance carrier does not accept “assignment of benefits,” I understand that all correspondence and payments for Infuserve America, Inc. may be sent directly to me. I agree that when such payments are received, I will hold them in trust for Infuserve America, Inc. for payment of my bill. I further agree to promptly remit such payments to Infuserve America, Inc., and acknowledge that failure to do so may be treated as non-payment for services rendered.
10. I understand that I can make payment for services by either personal check, or by endorsing the insurance payment by writing “pay to the order of Infuserve America, Inc.” and my signature. If the insurance payment is less than the outstanding bill, I understand that I will be personally responsible for the difference. I further understand that I am personally and ultimately responsible for all charges incurred, regardless of insurance coverage, benefit limitations, denials, or reversals. In the event of non-payment, I agree to pay all reasonable costs of collection, including attorney’s fees, court costs, and collection agency fees, to the extent permitted by law.
11. I also grant the right to Infuserve America, Inc. to obtain a copy of the insured’s policy from the insurer if necessary. If the insurer cannot release the full policy, I authorize release of relevant coverage information necessary for billing and payment purposes.
12. Should Infuserve be able to recover payment from my insurance, I understand Infuserve will reimburse me for corresponding payments I have made.
13. I certify that all information I provide to Infuserve America, Inc., including insurance coverage, is true and accurate to the best of my knowledge. I agree to notify Infuserve America, Inc. immediately of any change in my insurance, contact information, or health status.
14. I understand that Infuserve America, Inc. reserves the right to discontinue services for non-payment.

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.

This Notice of Privacy Practices ("Notice") describes the privacy practices of Infuserve America, Inc. (hereinafter referred to as "the Pharmacy", “We”, “Us”) and applies to all Protected Health Information (PHI) created or maintained by the Pharmacy. PHI is information about you, including demographic information that may identify you and relate to your past, present, or future physical or mental health or condition and related health care services.

We are required by law to maintain the privacy of your PHI and to provide you with this Notice of our legal duties and privacy practices with respect to PHI. We are committed to protecting your privacy.

1. Our Responsibilities Regarding Your PHI

We are required by law to:

• make sure that medical information that identifies you is kept private,
• give you this Notice of our legal duties and privacy practices with respect to your medical information,
• follow the terms of the Notice that is currently in effect,
• notify you if a breach occurs that may have compromised the privacy or security of your information.

2. How We May Use and Disclose Your PHI

The following categories describe different ways that we may use and disclose PHI. For each category of use or disclosure, we will explain what we mean and provide an example. Not every use or disclosure in a category will be listed.

• For Treatment: We may use and disclose PHI to provide, coordinate, or manage your health care and any related services. This includes coordinating your care with other health care providers, such as your physician, nurses, or other pharmacies involved in your care.
• For Payment: We may use and disclose PHI so that we can bill and collect payment from you, your insurance company, or a third party.
• For Healthcare Operations: We may use and disclose PHI for our internal operations necessary to run our pharmacy and improve the quality of care we provide. This includes activities such as quality assessment and improvement, conducting training programs, accreditation, certification, licensing, and general administrative activities.
• To Individuals Involved in Your Care or Payment for Your Care: We may disclose PHI about you to a family member, relative, close friend, or any other person you identify who is involved in your care or payment for your care, if you tell us, you have no objection or if we infer your permission.
• For Appointment Reminders/Treatment Alternatives/Health-Related Services: We may use and disclose PHI to contact you with appointment reminders, or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
• For Research Purposes: We may use or disclose your PHI for research purposes under certain limited circumstances, such as when approved by an Institutional Review Board (IRB) or Privacy Board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
• Required by Law: We will disclose PHI about you when required to do so by federal, state, or local law.
• To Avert a Serious Threat to Health or Safety: We may use and disclose PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
• Health Oversight Activities: We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.
• Law Enforcement: We may disclose PHI 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 if, under certain limited circumstances, we are unable to obtain the person's agreement,
  • about a death we believe may be the result of criminal conduct,
  • about criminal conduct at the pharmacy,
  • 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.
• Judicial and Administrative Proceedings: We may disclose PHI during any judicial or administrative proceeding in response to a court order, subpoena, discovery request, or other lawful process.
• Coroners, Medical Examiners, and Funeral Directors: We may disclose PHI to a coroner or medical examiner to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.
• Organ and Tissue Donation: We may disclose PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue to facilitate organ or tissue donation and transplantation.
• Military and Veterans: We may disclose PHI about you as required by military command authorities if you are a member of the armed forces.
• Workers' Compensation: We may disclose PHI for workers' compensation programs or similar programs that provide benefits for work-related injuries or illnesses.
• Public Health Activities: We may disclose PHI to public health authorities authorized by law to prevent or control disease, injury, or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; or notify people of product recalls.
• Victims of Abuse, Neglect, or Domestic Violence: We may disclose your PHI to a government authority authorized by law to receive reports of abuse, neglect, or domestic violence if we believe that you have been a victim of abuse, neglect, or domestic violence.
• Correctional Institutions: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose PHI to the correctional institution or law enforcement official as necessary for your health and the health and safety of other individuals.

Notice of Privacy Practices

3. Uses and Disclosures Requiring Your Written Authorization

We will not use or disclose your PHI for purposes other than those described in this Notice without your written authorization. Specifically, your written authorization will be required for:

• marketing: Most uses and disclosures of PHI for marketing purposes,
• sale of PHI: Disclosures that constitute a sale of PHI,
• psychotherapy Notes: Most uses and disclosures of psychotherapy notes (if applicable).

You may revoke an authorization at any time, in writing, except to the extent that we have already acted in reliance on the authorization.

4. Your Rights Regarding Your PHI

You have the following rights regarding your PHI:

• Right to Inspect and Copy: You have the right to inspect and obtain a copy of PHI that may be used to make decisions about your care. We may charge a reasonable, cost-based fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to PHI, you may request that the denial be reviewed.
• Right to Amend: If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Pharmacy. 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 longer available to make the amendment,
  • is not part of the PHI kept by or for the Pharmacy,
  • is not part of the information which you would be permitted to inspect and copy,
  • is accurate and complete.

If we deny your request, we will provide you with a written explanation of the denial. You have the right to submit a statement of disagreement with our denial.

• Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of certain disclosures we have made of your PHI. This list will not include disclosures made for treatment, payment, or healthcare operations, or disclosures made to you, or disclosures for which you provided authorization. To request an accounting of disclosures, you must submit a request in writing, stating the period desired (which may not be longer than six years prior to the date of your request). The first accounting you request within a 12-month period will be free. For additional accounting, we may charge a cost-based fee.
• Right to Request Restrictions: You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.
  • We are not required to agree to your request, unless you request that we restrict disclosure of your PHI to a health plan for a healthcare item or service for which you have paid out-of-pocket in full, and the disclosure is for the purpose of carrying out payment or healthcare operations and is not otherwise required by law.
  • If we do agree to a restriction, we will comply with your request unless the information is needed to provide emergency treatment.
• 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. We will accommodate all reasonable requests.
• Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice. You may ask us for a paper copy of this Notice at any time, even if you have agreed to receive this Notice electronically.

5. Changes to This Notice

We reserve the right to change this Notice at any time. We reserve the right to make the revised or changed Notice effective for medical information we have about you as well as any information we receive in the future. We will post a copy of the current Notice on our website at https://www.infuserveamerica.com and in our pharmacy premises. You may also obtain a copy of the current Notice by contacting the Privacy Officer.

6. Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Pharmacy or with the Secretary of the Department of Health and Human Services. To file a complaint with the Pharmacy, please contact:

Privacy Officer: Sarkis Knyazyan

Phone: (800)-886-9222

E-mail: sarkis@infuserveamerica.com 

Mailing Address: 11880 28th St, St. Petersburg, FL 33716 

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775 (toll-free), or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

We will not retaliate against you for filing a complaint.

Patient’s Bill of Rights and Responsibilities

1. Every patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy. This includes being provided with the organization’s Notice of Privacy Information, including privacy of Protected Health Information, and the agency’s policies regarding disclosure of such.
2. A patient has the right to prompt and reasonable response to questions and requests.
3. A patient has the right to know who is providing medical services and who is responsible for his or her care, and the right to freely choose health care providers and services. You also have the right to be informed of any limitations the providers may have.
4. A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
5. A patient has the right to know what rules and regulations apply to his or her conduct.
6. A patient has the right to be given, by the health care provider, information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis. The patient should participate in planning his/her care and services.
7. A patient has the right to refuse any treatment, except as otherwise provided by law.
8. A patient has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care.
9. A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate.
10. A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care, medications and supplies.
11. A patient has the right to be informed of any financial benefits when referred to an organization.
12. A patient has the right to receive a copy of a clear and understandable, itemized bill and, upon request, to have the charges explained.
13. A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, sexual orientation, or source of payment.
14. A patient has the right to receive treatment for any emergency medical condition that could deteriorate without care.
15. A patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research.
16. A patient has the right to express grievances regarding any violation of his or her rights, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency.
    In the event a complaint/grievance arises regarding service provided you by Infuserve America please call a Case Manager at 1-800-886-9222 to report.
    Our Case Managers will work to resolve all issues reported to them. If unable to resolve the issue, the Case Manger will notify the Case Management Director.
    Appropriate upper management will be notified/consulted for resolution and mitigation of any further issues when needed.
    If time is needed to investigate your complaint/grievance you will receive a follow-up call within 48 business hours.
    If Infuserve America is unable to resolve your concerns, you are encouraged to report your concern to Accreditation Commission for Health Care (ACHC) at (855)-937-2242 or via the website https://www.achc.org/pharmacy.html
17. A patient is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.
18. A patient is responsible for providing accurate insurance information and promptly responding to requests from Infuserve America or insurer related to billing or coverage.
19. A patient is responsible for reporting unexpected changes in his or her condition to the health care provider.
20. A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
21. A patient is responsible for following the treatment plan recommended by the health care provider.
22. A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider or health care facility.
23. A patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider's instructions. This includes requesting refills for prescribed medications.
24. A patient is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as possible.
25. A patient is responsible for following health care facility rules and regulations affecting patient care and conduct.