Use Instructions
302
Appendix
Customer's Bill of Rights and Responsibilities
You have the right to:
1. Receive considerate and respectful service.
2. Receive service without regard to race, creed, national origin, sex, age,
disability, sexual orientation, illness, or religious aliation.
3. Expect condentiality of all information pertaining to you, your medical care
and service. Please review our HIPAA Privacy Notice later in this section.
4. Receive a timely response to your request for service.
5. Receive continued service.
6. Select the medical equipment supplier of your choice.
7. Make informed decisions regarding your care planning.
8. Understand what services will be provided to you.
9. Obtain an explanation of charges, including policy for payment.
10. Agree to or refuse any part of the plan of service or plan of care.
11. Voice complaints without fear of termination of service or other reprisals.
12. Have your communication needs met.
You have the responsibility to:
1. Ask questions about any part of the plan of service or plan of care that you do
not understand.
2. Use the equipment for the purpose for which it was prescribed, following
instructions provided for use, handling care, safety and cleaning.
3. Supply Insulet Corporation with insurance information necessary to obtain
payment for services.
4. Be accountable for charges not covered by your insurance. You are
responsible for settlement in full of your account.
5. Notify us immediately of:
a. Equipment failure, damage or need of supplies.
b. Any change in your prescription or physician.
c. Any change or loss in insurance coverage.
d. Any change of address or telephone number, whether permanent or
temporary.
Effective Date: 22DEC2020, PCO-000267