Infusion Patient Resource Guide

Coram Patient Resource Guide 1 Welcome to Coram At Coram® CVS Specialty® Infusion Services (Coram), we’re here to help make things a little easier. We know that starting infusion therapy at home will require some changes for you. At first, you may feel stressed—but we’re ready to help. Coram will provide ongoing education, care and support. We want to help you achieve success with your infusion therapy. We’re here for you every step of the way. Each day, skilled Coram nurses and dietitians work together. We provide complex infusion care to thousands of patients. The skilled staff at Coram will work as a team, along with your doctor, to arrange all aspects of your care. Your Coram care team can be reached 24 hours a day, every day, to answer questions about your health, medications, equipment or supplies. At every turn, Coram will help you stay on your path to better health. We work hard to make sure you always get the best care and personalized support to help you meet your health care needs. This guide will introduce you to the Coram team and provide you with facts about your infusion therapy. Please use this guide as a resource during your therapy.

1 Contents

Your Home Infusion Therapy Support...... 3 Managing Your Medication and Supplies...... 3 Waste Disposal...... 4 Infusion Therapy...... 5 How to Care For and Manage Your IV Catheter ...... 6 How to Administer Your Infusion Therapy ...... 7 Steps for Success with Your Home Infusion Therapy ...... 8 How to Contact Coram...... 9 Frequently Asked Questions (FAQ)...... 9 Lifestyle Considerations...... 10 Home Safety ...... 10 Medical and Emergency Considerations ...... 12 Glossary ...... 13 Self-Monitoring Chart...... 14 Forms and Notices...... 15 • Patient/Caregiver Acknowledgement ...... 17 • Notice of Privacy Practices (NOPP) ...... 18 • Patient Rights and Responsibilities ...... 21 • Medicare Prescription Drug Coverage and Your RIghts ...... 23 • Centers for Medicare & Medicaid Services (CMS) Medicare Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) Supplier Standards ...... 23 • Nondiscrimination and Accessibility Notice (ACA § 1557) ...... 25 • Advance Directives ...... 25

Please find our Notice of Privacy Practices onpage 18.

Bill Payment Online. For fast, easy bill payment, visit coramhc.com. Click on Pay Your Bill in the upper right-hand corner. You can pay invoices by credit or debit card. You will receive a confirmation number and payment receipt.

By Phone. Please call 1-855-311-7246 to pay an invoice over the phone using a credit card. You will receive a receipt by email or by U.S. Postal Service (USPS) mail. Your Home Infusion Managing Your Medication Therapy Support and Supplies Coram provides the medication, equipment and supplies your doctor has prescribed for you. We Initial Delivery provide the information and support you will Your initial delivery of supplies to your home will need to succeed with infusion therapy at home. vary depending on your specific needs. It may include an infusion pump and pole, medication Your Coram Team and Resources and other supplies. Your Coram team is highly skilled. They will work There are several forms and notices that will closely with you and your doctor. You can reach require your review. You might also need to sign them around the clock, seven days a week. a form for this first delivery. Feel free to ask any You can contact them whenever you have a questions, and keep copies for your files. question. • Pharmacist: Prepares your medications and Refills and Clinical Follow Up solutions, answers questions about your Your Coram team will contact you regularly. medications, supplies and equipment and They will help you keep track of the amount checks on your response to therapy and for of medication and supplies you need for your any drug reactions. therapy. Your Clinical Support Specialist will • Nurse: Administers and teaches you to handle contact you often to find out what you need. your home infusion therapy, checks on your They will arrange for delivery to your home at a response and the status of your intravenous time that is best for you. Please let your Clinical (IV) catheter. Support Specialist know if you need more or less of any supply. You don’t want to have too • Dietitian: Reviews your nutritional needs, many supplies that you will not be using. teaches you about your therapy and checks on your response to your nutrition therapy (if It’s important that you and your Clinical Support prescribed by your doctor). Specialist communicate often. This should happen before each delivery. It is extremely • Clinical Support Specialist: Calls you on a important to make time to tell them about regular basis to find out how you are doing, your current health status. Also let them know and arranges for delivery of medications and how things are going with your home infusion supplies needed for your therapy. therapy. These questions may take a few • Reimbursement and Insurance Specialist: minutes to answer. Remember, this is a very Helps you with any financial concerns and important part of your care. answers your questions about charges or payment terms. Expect routine calls from your Clinical Support Specialist. Be ready to tell him or her about: • Prescription changes — if your doctor adds or changes any of the items on your prescription. Also let your pharmacist know if this happens. • Damaged/defective items — if any items arrive damaged or defective. Save the damaged item in its original package, if possible, for return to Coram. • Changes in amount — if you need more or less of any items. Please let us know so we can adjust your supplies.

Coram Patient Resource Guide 3 • Missed inventory check — if for any reason Waste Disposal you are not able to review your inventory as scheduled. Please call us ahead of time to Depending on your therapy, you may need make other plans. to use the Sharps/Medical Waste disposal • Interruption of therapy — if you return to the system.* Coram will provide you with a Sharps hospital, or if your doctor has stopped your container, if needed. treatment. Please notify Coram at once. Dispose of the following items in your Sharps • Issues with your infusion pump (if applicable) container: — if you have any questions or problems with • Used IV catheters the operation of your pump. Let us know if you need to exchange it. • Used needles • Used cannulas Delivery of Supplies • Any items contaminated with chemotherapy or other hazardous drugs, including empty IV Your supplies will arrive by carrier. These may bags and tubing be delivered by a Coram employee, a courier or a service such as FedEx or UPS. Using the Sharps System Inspect all your supplies when they arrive. Before you sign the delivery ticket, check to see • Remove the Sharps container from the box. that it matches what you received. You will be • Save the box and bag for returns. given a copy of the ticket. You may be asked • Place all required waste into the container to return a signed copy. Call Coram while the until it is three‑quarters full. delivery person is still at your home if you have any questions about a delivery. • Do not pour any fluid into the container. Your infusion supplies are part of your • Once the container is three‑quarters full or no prescription. Because of state laws, Coram longer needed, close the lid. cannot accept any returns of unused supplies • Place the container inside the plastic bag. and products. • Use the twist‑tie to close the plastic bag. Infusion Pumps • Place the closed plastic bag with the Sharps container inside the box. Your therapy may require the use of an infusion • Always keep the Sharps container out of pump. This pump is a costly and delicate piece reach of children and pets. of equipment. You will be asked to sign a Pump Responsibility Agreement. You will be asked to Please contact your Clinical Support Specialist keep track of it during your therapy and return it before you return your Sharps container and when your therapy is finished. order a new one. If you have questions about Pumps require periodic testing and the Sharps system, let him or her know. maintenance. Coram may need to exchange your current pump in order to do this. Returning your Sharps Container Your Clinical Support Specialist will contact you Return instructions will depend on the type of to exchange or return your pump at the right container you received. You may either: time. You will be given a pre-paid shipping box • Give the container to your mail carrier or take with your pump supplies. Save this box to use it to the nearest post office to exchange or return your pump. Coram will make arrangements with UPS to pick up your • Expect a pick up from UPS boxed pump. Please contact your Clinical Support Specialist if at any time you have a question or concern about your pump.

Coram Patient Resource Guide 4 Infusion Therapy Infusion therapy takes place when medicine is given directly into your bloodstream. This is done through a small device placed through the skin and into a vein. The device is called an IV catheter. The catheter may need to be placed into the vein during a surgical procedure. This catheter may remain in your body for a period of time. Your doctor will decide which of the following devices is best for you. Types of IV Catheters • Peripherally Inserted Central Catheter (PICC): a plastic tube that is inserted into a • Peripheral IV Catheter: a short plastic tube vein in your upper arm. The tip of the catheter that is put through your skin into a vein. Most ends in a blood vessel above the heart. This often, this is done in your hand or arm to give type of catheter can stay in place for a year or medications and fluids. more. It can be used for a large variety of therapies.

• Midline Catheter: a plastic tube, three to six inches in length, that is inserted into a vein in • Tunneled Central Catheter: a plastic tube that your upper arm. The tip of the catheter ends is put into a large vein in your neck, chest or below your arm pit. This type of catheter is groin. It can be tunneled under your skin or typically used for therapies lasting less than inserted into the vein directly. It can stay in one month. place for a long time. It can be used for a large variety of therapies.

Coram Patient Resource Guide 5 • Implanted Port Catheter: a round metal disc all necessary information. Some of the tools can with a soft rubber dome/top that is inserted be found in this booklet. Refer to the SASH mat under the skin in your chest (usually) during in the pocket of this Patient Resource Guide surgery. It is completely covered by your skin. for more information on how to avoid catheter A special needle is pushed through your skin complications. (“SASH” stands for: Saline flush, into the disc in order to give the medication. A Administration, Saline flush,H eparin flush — port can stay in your body for years. It can be these are steps you will learn about for flushing used to draw blood or give you medication. your catheter and administering medication.)

Top Tips to Prevent Catheter Complications Follow all directions and tips to help avoid complications with your catheter. • It is important to wash your hands. Do this before and after you work with your catheter, medication and supplies. This will help prevent infection. • The tip of the saline and heparin syringes are sterile. Do not touch them, or let them touch any surfaces. If this happens, discard this syringe and use a new syringe. • Use a new alcohol pad for each step. Be sure to scrub your catheter injection cap for at least 15 seconds with an alcohol pad before each access. In some cases, your medicine may be given • Do not force a catheter flush. Stop and through a subcutaneous catheter. This is when call your nurse if you have pain, burning or medicine is given beneath your skin, not in a swelling when flushing. vein. Certain special medications may be given this way. Your nurse will explain more if needed. • Clamp the catheter and/or extension set when not in use. Local Infusion Suites • Keep the catheter dressing and catheter injection cap covered while bathing. Coram infusion suites may be a convenient option for you to receive your infusion. The • Make sure that the catheter is secured. Do not skilled nurses and pharmacists in our suites will let the extension set or tubing dangle. give you quality care in a clean, comfortable and • Do not use scissors, pins or other sharp safe setting. You can plan your day by having objects near the catheter or tubing. your infusion scheduled at a time that works best for you. Please call your branch to learn more about infusion in our infusion suite. Tell your nurse and/or doctor if you have any pain, redness, coolness or swelling at the site How to Care For and where the IV catheter is located. While receiving Manage Your IV Catheter infusion therapy, you will be asked to help look for signs of possible trouble with your IV You may be taught to help care for your IV catheter (access device). This includes redness, catheter. This will depend on your catheter. You swelling, pain or drainage around the device. may be taught to flush if you have a catheter that You should check for these signs daily, or when remains in between medication doses. This will you receive each dose. Please call your nurse depend on your doctor’s orders. Your nurse will or pharmacist as soon as possible if you have teach you what level of care is needed. You will any trouble with your IV device. You will also be given training tools to be sure that you have want to contact your doctor.

Coram Patient Resource Guide 6 How to Administer Your 2. An ideal work surface is your SASH mat, located in the pocket of this Patient Infusion Therapy Resource Guide. 3. Choose another work surface that can be Before You Begin cleaned often if you don’t have your SASH 1. Clean your work area. mat (e.g., a tabletop or a metal or plastic 2. It is important to wash your hands to help tray). Your nurse will help you decide on a prevent infection. Do this before and after work surface. you work with your catheter, medication 4. Clean your work area again if it gets dirty and supplies. For best results, use a liquid during use. Keep pets and children away soap rather than a bar soap. Follow the from your work area. instructions in the Proper Handwashing Technique section of this guide. Reminders 3. Prepare your medication. Refer to your • Make sure all clamps are open if it is hard to medication label for details on how to handle push in the plunger while flushing. and store medication. If your medication is refrigerated, allow it to warm up to room • Do not force a flush.Stop and call your nurse temperature before you use it. Do not place if you have pain, burning or swelling. it in hot water, sunlight or a microwave to • Do not reuse any syringe. speed up the process. • If you have a double-lumen catheter, flush 4. Inspect the medication and label for: each lumen as directed by your nurse. –– Correct patient name, drug name, dose and drug route (IV or subcutaneous) Do not smoke while preparing your work area, –– Expiration date handling your supplies or during your infusion treatment. –– Solution that is clear, consistent in color and free of any visible particles Warm Solution Containers to Room Temperature Note: If you have a back-up pump, rotate Solution containers should be removed from the pumps with each change of the medication refrigerator and warmed to room temperature bag/cassette. before using. This may take 30 minutes to four hours, depending on the size of your container. Refer to the instructions you received with your Choosing and Preparing Your solutions. Work Area The container is ready to use when it feels cool 1. Your work area should be clean, and free of (but not cold) to the touch. dust, drafts and clutter. DO NOT attempt to warm your solution containers in the microwave, by placing them in boiling water or in direct sunlight.

Coram Patient Resource Guide 7 Steps for Success with Your For best results, use a liquid soap rather than a bar soap, and follow these instructions: Home Infusion Therapy 1. Turn on the sink tap and wet your hands and wrists under warm running water.Leave the Storing and Handling Refrigerated tap on. Solutions Refrigerated solutions should be stored at a temperature between 36°F and 46°F. If you can, create a space in your refrigerator that is just for your medications/solutions. Solutions should be in a sealed plastic bag if they are stored on a lower refrigerator shelf or beneath food and/or beverages.

2. Apply enough liquid soap to cover all hand surfaces. Rub hands together, palm to palm, covering all surfaces of both hands, all fingers and your thumbs. Rub the soap in between your fingers and on top of your hands. Use a nail brush if needed. Scrub thoroughly for at least 20 seconds, or as long as it takes to sing “Happy Birthday” twice. 3. Rinse your hands to remove all soap and dry them thoroughly. Dry them with a paper towel or clean (unused) hand towel. 4. After drying your hands, use the same towel to turn off the faucet.Do not touch the faucet directly with your clean hands.

Proper Handwashing Technique Washing your hands is very important! Make sure you clean your hands: • Before and after you work with your catheter, medication and supplies • After using the restroom • After blowing your nose, or covering your mouth and nose to cough or sneeze • Additionally, as needed (e.g., if they become soiled) 5. Once your hands are clean, make sure they do not come in contact with unclean Wash your hands with soap and water, and surfaces. You will need to rewash your dry them thoroughly with a paper towel or use hands before continuing if you cough, hand sanitizer. sneeze or pick up something from the floor.

Coram Patient Resource Guide 8 Use an alcohol-based hand sanitizer if Frequently Asked Questions you don’t have immediate access to soap and water: (FAQ) 1. Apply a quarter-sized amount of hand gel Q: When should I call my doctor? into one palm. A: You should call your doctor if you notice: 2. Spread the gel between your hands and around all fingers. • Skin reactions like hives, flushed skin or paleness 3. Rub your hands together vigorously. • Nausea, vomiting or diarrhea and/or 4. Keep rubbing your hands together until they stomach pain are dry and all gel has been absorbed. • Fever greater than 100° F Covering Your Cough and/or Sneeze Call 911 right away if a life-threatening Covering your cough and/or sneeze helps emergency should occur during your therapy. prevent germs from entering the air space Coram is not an emergency care provider. shared by your family and friends. Ideally, use a tissue. Cough or sneeze into your elbow to avoid spreading germs onto your hands if a tissue is Q: When should I call Coram? not available. A: Call Coram if a situation is not life- Remember to always: threatening. Your Coram care team can help • Place used tissues in a trash can. with the following: • Wash your hands after you cough, sneeze or • If you can’t flush your IV catheter handle used tissues. • If there is swelling, redness or drainage from your IV catheter site • If you experience any unusual occurrence How to Contact Coram that would cause the infusion therapy to stop • If your IV catheter site dressing becomes wet or falls off Contact your local Coram branch by calling the number listed in your • If your pump is beeping and has an welcome letter for: error message 1. Medication and supply questions • If you have questions about your medication 2. Customer service questions 3. Billing questions and insurance Q: Are home infusion therapy and the changes necessary supplies covered by insurance? 4. Any questions or problems with your IV access device A: This depends on your insurance type and coverage rules. Coram will find out what is 5. Problems/alarms related to your covered and let you know about any out-of- pump pocket costs before the start of care.

Q: What other resources are available to learn more about home infusion therapy? A: Your Coram nurse or pharmacist can help you learn more about your therapy. Patient education materials are also available on coramhc.com.

Coram Patient Resource Guide 9 Lifestyle Considerations Home Safety Coram wants to help you on your path to better An important part of taking care of your health health. We also want to help you continue with is making sure that your home is safe for you activities that are important to you. and your caregivers. You should know how to operate and care for your medical devices. Bathing and Swimming Taking steps to prevent fires or falls can help prevent accidents or emergencies. You may keep up with routine bathing habits.

It is very important to protect your IV catheter 1 and equipment from water. Your Coram team Oxygen Safety will teach you how to do this. Ask your doctor if • Never smoke or allow others to smoke near swimming is permitted. where oxygen is stored or being used. Speak to your oxygen company about getting “no Entertainment and Exercise smoking” signs for your home. As you start to feel better, you may slowly return • Keep oxygen canisters at least five to 10 feet to activities you like to do with friends and away from any heat source or open flame. family. Make sure to check with your doctor This includes heaters, gas stoves, fireplaces, first. Your level of energy may change from wood-burning stoves, candles, etc. Keep day to day. Check with your doctor before any oxygen away from things that can cause a strenuous exercise. spark like electric heaters, blankets and hair dryers. Remember to always be careful with your IV catheter. Try not to pull or apply any pressure to it. • Make sure tanks stand upright. Hold them in place using an approved holder/cart provided by your oxygen company. You may lay oxygen Travel tanks on the floor if you do not have a way to We can help you with important travel details. secure them upright. We have tips to help you plan and pack for • Do not use extension cords or multi-outlet your trip. Our patient advocates can let the adaptors, such as power strips, near your Transportation Security Administration (TSA) oxygen. know about your specific medical needs. Please allow at least 72 hours advance notice • Know how your oxygen equipment works. before traveling by air. • Check the amount of oxygen that is in your It is important that you tell your doctor of your tank on a routine basis. Let your oxygen desire to travel. Also let your Coram team know company know if you are running low on two weeks in advance of your trip, when possible. oxygen. This will make it easier for you to go through • In case of a power outage, let your utility/ airport screening. If it’s urgent that you travel by power company know that you have oxygen air with less than 72 hours’ notice, you should and need it. call the TSA Cares hotline at 1-855-787-2227. Tell • Avoid storing your oxygen tanks in an area TSA about your medical needs and request help exposed to the sun. at the screening checkpoint. • Do not use oil- or petroleum-based products You may need to get an order from a doctor while using oxygen—use water-based lotions with a license in the state you are visiting if you and products. will need nursing services while traveling. Your • Keep the phone number for your oxygen Coram branch team can also help you if you will and equipment company nearby in case have continued coverage for your therapy in the something breaks or you need to order more state or country you are visiting. If you plan to oxygen. travel out of the country, let Coram know at least one month before you leave so we can help • Do not change your oxygen dosage unless you learn how you can safely travel with your your doctor tells you to change it. medication and/or nutrition. For more helpful • Turn your oxygen off when you are not using it. travel resources, visit coramhc.com.

Coram Patient Resource Guide 10 Fire Safety2 Fall Prevention3 • Have a smoke detector/alarm on each floor of • Consider these potential risks for falls. Talk to your home, preferably in all bedrooms. your doctor or nurse if you have any of these: • Check the smoke detectors/alarms each –– Problems with balance, leg weakness or month and make sure they work. Change the dizziness—Can you stand or walk without batteries if not working. Check with your local losing your balance or becoming unsteady fire department for help if you need smoke on your feet? Do you need to hold onto detectors/alarms. furniture or walls when walking? Are your • Never smoke or allow others to smoke near legs or feet feeling numb? where oxygen is stored or being used. –– Vision issues—Do you have any problems • Keep matches and lighters out of children’s seeing things clearly? reach and sight. –– Medications—Are you taking any • Do not smoke if you are drowsy, have taken medications that make you sleepy, “shaky” pain medication or are resting in bed. on your feet, weak, dizzy or dehydrated? • Plan your escape route from different places –– Other conditions—Do you have any other in your home. Have a designated spot where illnesses or conditions that make you weak everyone will meet after getting out of the or at risk for falling (e.g., needing to go to house. the bathroom quickly)? • Keep a fire extinguisher (in good working • Use a cane or walker if you have any of the order) in the kitchen and any other area where above conditions. a fire could happen (e.g., basement). • Talk to your doctor if you need help. • If someone is on fire: stop, drop and roll. • Make sure you have rails to hold onto when • If there is a fire in your home, first get going up and down stairs. everyone out. Then call 911 or the fire • Have grab bars in the bathroom near the toilet department right away, once out of the house and shower/bath. and safe. • Remove clutter from walking areas around your home. • Make sure the pathway between your bed and other resting areas and to bathrooms is clear and well lit. • Increase lighting throughout your house, especially at the top and bottom of your stairs. Use nightlights to keep paths visible. • Secure or remove throw rugs. • Cover or remove sharp corners along your bed, hallways and other pathways. • Keep all cords out of walking pathways. • Walk carefully around pets to prevent tripping. • Let your doctor and Coram nurse know if you have fallen.

Coram Patient Resource Guide 11 Medical and Emergency When Your Therapy Ends Considerations You may stop services with Coram for any of these reasons: Adverse Drug Reactions • Your treatment is finished. Call your doctor right away if you have any • Your doctor gives Coram an order to feelings you didn’t expect after you receive your discharge you. medication. Also call the Coram pharmacist at • Your doctor does not renew your orders. the branch number you received. You may also report side effects to the U.S. Food and Drug • You change doctors and do not have orders Administration (FDA) by calling 1-800-FDA-1088 from the new doctor. (1-800-332-1088). • Your original therapy orders have an end and discharge date. MinuteClinic® • You have been hospitalized. Many of the concerns that bring people to an • You decide you no longer need emergency department can be treated in walk- Coram services. in medical clinics. MinuteClinic is the clinic • You refuse treatment. inside CVS Pharmacy® and Target stores. It has certified nurse practitioners and physician • Infusion therapy can no longer be safely given assistants who may be able to help.† If you can’t in your home. reach your doctor, you can go to MinuteClinic • You have not received therapy for more than seven days a week, including evenings. No 60 days (unless doctor’s orders say this is appointment is necessary. alright). Call 911 or your local hospital emergency • You move outside of the service area. department if you have a medical emergency. • Coram can no longer meet your MinuteClinic might be a convenient alternative health care needs. if it is not life-threatening and you still need to seek treatment. Visit coramhc.com to explore these Alcohol and Other Medications features and more: Alcohol and other prescription or • Educational resources non‑prescription medications may change how you react to your home therapy. Tell your • Patient stories pharmacist or nurse if you drink any alcohol or • How-to videos take any other medications. Also let them know if you have any changes in your medications. • Coram travel support program

Other Medical Treatment Please let your doctor or dentist know that you are on home IV therapy before any surgery or dental work.

In Case of Emergency or Disaster Please refer to the Welcome Letter in the front of this Patient Resource Guide. You will find helpful contact information and steps to follow in case of an emergency or disaster in your area.

Coram Patient Resource Guide 12 Glossary • Infection: The invasion of bacteria or virus in the body which causes your body to react and • Administration Set: Plastic tubing used to become ill. Antibiotics are sometimes used to administer IV fluids or medications. fight the infection. • Antibiotics: Drugs that fight infection by killing • Infusion Device: A device that controls the or stopping the growth of specific germs and speed (rate) of a solution as it enters the vein bacteria. through the catheter. • Advance Directive: A written statement of • Insertion Site: The place where the catheter a person’s wishes about medical treatment. enters the skin. This spells out in advance what actions should • Intravenous (IV): Inside a vein. be taken if a person is no longer able to make health care decisions for themselves because • Milliliter (ml): A unit of measurement for a of illness or incapacity. liquid or medication • Bacteria: Germs that attack the body and can • Needleless System: A system used to enter make you sick. the catheter in the vein that does not use any sharp metal needles. This system stops the • Cannula: Part of a catheter; a plastic tube for risk of accidental injuries caused by needles. medication infusion. • Parenteral Nutrition: A method of nutrition in • Catheter: A device with a plastic tube that is which a special sterile liquid nutrient mixture inserted/put into the body. The catheter can is given into the blood through an IV catheter. be used to administer fluids or medications or to draw blood. • Peripheral Catheter: A short IV catheter typically inserted in the hand or arm. • Catheter Injection Cap: A small cap attached to the end of the IV catheter to allow the • Side Effect: An undesired result of taking a administration of medication and prevent the medication or therapy. entry of air or germs into the catheter. • Sterile: Completely free from bacteria. • Central Catheter: An IV catheter that is Most supplies packed in sealed containers threaded through a vein to a point close to are sterile. the heart. • Sterile End Cap: A cap used to keep the end • Contaminate: To put bacteria on a sterile area of your administration tubing sterile. It is by contact with objects which are not sterile used when you are receiving more than one (such as ungloved hands). dose of medication in a 24-hour period, or as directed by your clinician. • Dehydrated: Body does not have enough water, which can create a feeling of weakness • Syringe: A plastic tube with a plunger that is and lightheadedness. used to administer medications. • Dressing: A sterile pad or clear covering over • Transparent Dressing: A thin sheet of see- a site where the IV is inserted or where there is through material to cover a site where an IV a wound. The covering protects the site from catheter is placed or over a wound to protect becoming infected or dirty. it from getting dirty or infected. • Enteral Nutrition: Also known as tube feeding. • Visit: Scheduled time your nurse will come to A way of delivering nutrition through a tube your home or other place to administer your directly into the stomach or small intestine. infusion medicines • Expiration Date: The last date a medication or supply can be used. • Flush: To clear out the solution remaining in the catheter or tubing. • Gastrointestinal (GI) Tract: Consists of the mouth, throat, esophagus, stomach and intestines; where food travels to be absorbed by the body. • Heparin: A medication used to prevent blood from clotting and blocking the catheter.

Coram Patient Resource Guide 13 Self-Monitoring Chart Your nurse may ask you to monitor important information (e.g., weight, temperature, blood pressure, etc.). Use this page to keep track of it. Bring this chart with you to medical appointments and share it with your health care provider.

Date Weight Temperature Blood pressure Input/Output

Coram Patient Resource Guide 14 Forms and Notices

There are several forms and notices in this folder that require your attention. Any signed form will be part of your medical and financial file.

Coram Patient Resource Guide 15 Contents: Forms and Notices

Assignment of Benefits (AOB)/Consent Form...... front pocket The Assignment of Benefits (AOB)/Consent Form authorizes Coram to bill your insurance provider. This form also shows that you agree to receive the services as prescribed by your doctor.

Financial Agreement Arrangement (FAA) Form...... front pocket Coram will check your insurance before you start services. We will tell you about the financial arrangements. You will be asked to sign an FAA form related to billing and payment for services. Your insurance is checked monthly. Coram will also verify your insurance again if you are hospitalized or return to our service.

Advance Beneficiary Notice (ABN) Form (Medicare patients only). . . . . front pocket An ABN form lists items or services that Medicare isn’t expected to pay for, an estimate of the costs for the items/services and reasons why Medicare may not pay.

Patient/Caregiver Acknowledgement...... 17 You will be asked to sign this form to confirm the information you received in this packet. You can note any questions you may have about the material on this form. A Coram team member will then follow up with you for more training.

Notice of Privacy Practices (NOPP) ...... 18 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 and ask your Coram team if you have any questions.

Patient Rights and Responsibilities...... 21 This form is located at the end of this booklet. Please read it carefully and ask your Coram team if you have any questions.

Medicare Prescription Drug Coverage and Your Rights...... 23 This form is located at the end of this booklet. It explains the steps you can take if you have questions about your coverage if you are on a Medicare drug plan.

Centers for Medicare & Medicaid Services (CMS) Medicare Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) Supplier Standards. . . . 23 This form explains the standards that medical suppliers must follow to comply with Medicare laws.

Advance Directives...... 25 You will be asked to sign this form to explain to health care providers and your family your wishes to accept or refuse services that could save or sustain your life.

Nondiscrimination and Accessibility Notice (ACA § 1557) ...... 25

Coram Patient Resource Guide 16 Patient/Caregiver Acknowledgement

A Coram team member will review the materials included in this packet with you. This signed form will be retained in your records.

Forms and Notices Section: Other: Notice of Privacy Practices (NOPP)

Front Pocket: Other: Welcome letter Other: State advance directive forms AOB/Consent form Other: FAA form Other: ABN form

Other: Back Pocket: Medication profile from HC360 I have no questions at this time regarding the Copy of physician orders drug therapy provided by Coram. I do not need to have a clinical pharmacist contact me Pump programming verification at this time to answer questions. I understand Drug information sheet that I may contact the pharmacy at any time if Patient education tools questions do arise. Pump information guide (manufacturer) I have questions regarding this drug therapy. Please have a clinical pharmacist contact me as SASH preparation mat soon as possible. Administration guides The best time to reach me is: .

Please call me at: .

The undersigned acknowledges that he/she has received, been instructed in, and understands the subjects covered in this packet and the additional materials included, as checked above.

Patient or Caregiver Signature Coram Representative Signature

Patient or Caregiver Printed Name Coram Representative Printed Name

Date of Patient or Caregiver Signature Date of Coram Representative Signature

Coram Patient Resource Guide 17 Notice of Privacy Practices (NOPP)

abuse records, and mental health records may be This notice describes how medical subject to additional confidentiality protections information about you may be used and under state or federal law. If you would like disclosed and how you can get access to this additional information about state law protections information. Please review it carefully. in your state, or additional use or disclosure restrictions that may apply to sensitive PHI, please contact the CVS Health Privacy Office. This Notice of Privacy Practices (the “Notice”) describes the privacy practices of Coram LLC (“CVS Health”) and the members of its Affiliated Uses and disclosures of your PHI for Covered Entity (“CVS ACE”). An Affiliated Covered treatment, payment and health care Entity is a group of Covered Entities and Health Care operations Providers under common ownership or control that We may use and disclose your PHI for treatment, designates itself as a single entity for purposes of payment and health care operations without your compliance with the Health Insurance Portability written authorization. The following categories and Accountability Act (“HIPAA”). The members of describe and provide some examples of the the CVS ACE will share Protected Health Information different ways that may use and disclose your PHI (“PHI”) with each other for the treatment, payment, for these purposes: and health care operations of the CVS ACE and as permitted by HIPAA and this Notice. For a complete Treatment: We may use and disclose your PHI to list of the members of the CVS ACE, please contact provide and coordinate the treatment, medication the CVS Health Privacy Office. and services you receive. For example, we may: PHI is information about you that we obtain to • Use and disclose your PHI to provide and provide our services to you and that can be used coordinate the treatment, medication and to identify you. It includes your name and contact services you receive at CVS Health. information, as well as information about your • Disclose your PHI to other third parties, such health, medical conditions and prescriptions. It may as pharmacies, doctors, hospitals, or other relate to your past, present or future physical or health care providers to assist them in providing mental health or condition, the provision or health care to you or for care coordination. In some care products and services to you, or payment for instances, uses and disclosures of your PHI for such products or services. these purposes may be made through a Health We are required by law to protect the privacy Information Exchange or similar shared system. of your PHI and to provide you with this Notice • Contact you to provide treatment-related explaining our legal duties and privacy practices services, such as refill reminders, adherence regarding your PHI. This Notice describes how we communications, or treatment alternatives (e.g., may use and disclose your PHI. available generic products). We have provided you with examples; however, not Payment: We may use and disclose your PHI to every permissible use or disclosure will be listed in obtain payment for the services we provide to this Notice. This Notice also describes your rights you and for other payment activities related to the and the obligations we have regarding the use and services we provide. For example, we may: disclosure of your PHI. • Share your PHI with your insurer, pharmacy We and our employees and workforce members benefit manager, or other health care payor to are required to follow the terms of this Notice or determine whether it will pay for your health care any change to it that is in effect. We are required products and services you need and to determine to follow state privacy laws when they are stricter the payment amount you may owe. (or more protective of your PHI) than the federal law. Note that some types of sensitive PHI, such as • Contact you about a payment or balance due for human immunodeficiency virus (HIV) information, prescriptions dispensed to you at CVS Pharmacy genetic information, alcohol and/or substance or may disclose your PHI to other health care

Coram Patient Resource Guide 18 providers, health plans or other HIPAA Covered prior expressed preference documented by CVS Entities who may need it for their payment Health. Upon your death, we may disclose your PHI activities. to an administrator, executor, or other individual authorized under law to act on behalf of your estate. Health care operations: We may use and disclose If you are a minor, we may release your PHI to your PHI for health care operations – those activities your parents or legal guardians when permitted or necessary to operate our health care business. For required by law. example, we may: Workers’ compensation: We may disclose your • Use and disclose your PHI to monitor the quality PHI as necessary to comply with laws related to of our health care services, to provide customer workers’ compensation or similar programs. services to you, to resolve complaints, and to Law enforcement: We may disclose your PHI to coordinate your care. law enforcement officials as permitted or required • Transfer or receive your PHI if we buy or sell by law. For example, we may use or disclose your pharmacy locations. PHI to report certain injuries or to report criminal • Use and disclose your PHI to contact you about conduct that occurred on our premises. We may health-related products, services or opportunities also disclose your PHI in response to a court order, that may interest you, such as programs for CVS subpoena, warrant, or other similar written request Health patients. from law enforcement officials. • Disclose your PHI to other HIPAA Covered Entities Required by law: We will disclose your PHI when that have provided services to you so that they required to do so to comply with federal, state or can improve the quality and efficacy of the health local law. care services they provide or for their health care operations. Judicial and administrative proceedings: We may disclose your PHI in response to a court or • Use your PHI to create de-identified data, which administrative order, subpoena, discovery request, no longer identifies you, and which may used or other lawful process. or disclosed for analytics, business planning or other purposes. Public health and safety purposes: We may disclose your PHI in certain situations to help with public health and safety issues when we Other uses and disclosures of your PHI are required or permitted to do so, for example that do not require authorization to: prevent disease; report adverse reactions to We are also allowed or required to share your PHI, medications; report suspected abuse, neglect or without your authorization, in certain situations or domestic violence; or to prevent or reduce a threat when certain conditions have been met. to anyone’s health or safety. Business associates: When we contract with third Health oversight activities: We may disclose your parties to perform certain services for us, such PHI to an oversight agency for certain activities as billing or consulting, these third party service including audits, investigations, inspections, providers, known as Business Associates, may need licensure or disciplinary actions, or civil, access to your PHI to perform these services. They administrative, and criminal proceedings, and as are required by law and their agreements with us to necessary for oversight of the health care system, protect your PHI in the same way we do. government programs, or compliance with civil rights laws. Individuals involved in your care or payment for your care: We may disclose your PHI to a friend, Research: Under certain circumstances, we may personal representative, family member, or any use or disclose your PHI for research purposes. For other person you identify as a caregiver, who is example, we may use or disclose your PHI as part involved in your care or the payment related to that of a research study when the research has been care. For example, we may provide prescriptions approved by an institutional review board and there and related information to your caregiver on your is an established protocol to ensure the privacy of behalf. We may also make these disclosures after your information. your death unless doing so is inconsistent with any

Coram Patient Resource Guide 19 Coroners, medical examiners and funeral Your health information rights directors: We may disclose PHI to coroners, Written requests and additional information: You medical directors, or funeral directors so that they may request additional information about CVS can carry out their duties. Health’s privacy practices or obtain forms for Organ or tissue donation: We may disclose your PHI submitting written requests by contacting the CVS to organ procurement organizations. Health Privacy Officer: CVS Health Privacy Office, One CVS Dr.,Woonsocket RI 02895 or toll-free by Notification: We may use or disclose your PHI telephone at (866) 443-0933. You can also visit to notify or assist in notifying a family member, www.coramhc.com to obtain the forms to submit personal representative, or any other person written requests. responsible for your care regarding your location, general condition, or death. We may also disclose Obtain a copy of the notice: You have the right to your PHI to disaster relief organizations so that your obtain a paper copy of our current Notice at any family or other persons responsible for your care time. You may do so by going to the site where you can be notified of your location, general condition, obtain health care services from us or by contacting or death. the CVS Health Privacy Office. Correctional institution: If you are or become an Inspect and obtain a copy of your PHI: With a few inmate of a correctional institution, we may disclose exceptions, you have the right to see and get a copy your PHI to the institution or its agents to assist of the PHI we maintain about you. You may request them in providing your health care, protecting your access to your PHI electronically. To inspect or health and safety or the health and safety of others. obtain a copy of your PHI, submit a written request to the CVS Health Privacy Office. You may also ask Specialized government functions: We may us to provide a copy of your PHI to another person disclose your PHI to authorized federal officials for or entity. A reasonable fee may be charged for the conduct of military, national security activities the expense of fulfilling your request as permitted and other specialized government functions. under HIPAA and/or state law. We may deny your request to inspect and copy your record in certain Uses or disclosures for purposes that limited circumstances. If we deny your request, we require your authorization will notify you in writing and let you know if you may Use and disclosure of your PHI for other purposes request a review of the denial. may be made only with your written authorization Request an amendment: If you feel that the PHI and unless we have your authorization we will not: we maintain about you is incomplete or incorrect, • Use or disclose your PHI for marketing purposes. you may request that we amend it. For example, if your date of birth is incorrect, you may request • Sell your PHI to third parties (except for in that the information be corrected. To request an connection with the transfer of a business to amendment, submit a written request to the CVS another health care provider required to comply Health Privacy Office. You must include a reason with HIPAA). that supports your request. If we deny your request • Share psychotherapy notes (to the extent we for an amendment, we will provide with you a have any). written explanation of why we denied it. Receive an accounting of disclosures: You have the right We will obtain your written authorization before to request an accounting of disclosures we make using or disclosing your PHI for purposes of your PHI for purposes other than treatment, other than those described in this Notice or payment, or health care operations. Please note otherwise permitted by law. You may revoke your that certain other disclosures need not be included authorization at any time by submitting a written in the accounting we provide to you. To obtain notice to the CVS Health Privacy Office. Your an accounting, submit a written request to the revocation will be effective upon receipt; however, CVS Health Privacy Office. We will provide one it will not undo any use or disclosure of your PHI accounting per 12-month period free of charge, but that occurred before you notified us, or any actions you may be charged for the cost of any subsequent taken based upon your authorization.

Coram Patient Resource Guide 20 accountings. We will notify you in advance of the Notification of breach:You have a right to be cost involved, and you may choose to withdraw or notified in the event there is a breach of your modify your request at that time. unsecured PHI as defined by HIPAA. You have Request confidential communications: To Report a Problem the right to request that we communicate with you in a certain way or at a certain location. For Complaints: If you believe your privacy rights have example, you may request that we contact you been violated, you can file a complaint with the only in writing at a specific address. To request CVS Health Privacy Officer or with the Secretary confidential communication of your PHI, submit a of the United States Department of Health and written request to the CVS Health Privacy Office. Human Services. All complaints must be submitted Your request must state how, where, or when you in writing. You will not be penalized or otherwise would like to be contacted. We will accommodate retaliated against in any way for filing a complaint. all reasonable requests. Changes to this Notice Request a restriction on certain uses and disclosures: You have the right to request additional We reserve the right to make changes to this Notice restrictions on our use and disclosure of your PHI as permitted by law and to make the revised Notice by sending a written request to the CVS Health effective for PHI we already have about you as Privacy Office. We are not required to agree to well as any information we receive in the future, your request except where the disclosure is to a as of the effective date of the revised Notice. If we health plan or insurer for purposes of carrying out make material or important changes to our privacy payment or health care operations, is not otherwise practices, we will promptly revise our Notice. required by law, and the PHI is related to a health Upon request to the Privacy Office, CVS Health will care item or service for which you, or a person on provide a revised Notice to you. We will also post your behalf, has paid in full out-of-pocket. If you the revised Notice in our retail stores and on our do not want a claim for payment submitted to your website at https://www.coramhc.com/privacy- health plan on record, please discuss with the policy and will make copies available at our facilities pharmacist or health care provider when you check and locations where you receive health care in for care or before your prescription is sent to the products and services from us. pharmacy. Effective Date: This Notice is effective as of September 30, 2019.

Patient Rights and Responsibilities

As a Patient, you have the right to: • Receive information as to your eligibility for insurance reimbursement and your responsibility • Receive complete information about your rights for any costs in advance of care provided. and responsibilities. • Be actively involved in developing and participating • Choose your healthcare provider and receive in a plan of care that will meet your identified information on service or care limitations or of any healthcare needs to the extent provided by law, as financial benefits when referred to Coram. well as discuss any problems, changes or barriers • A timely response from Coram notifying you in achieving goals. when products and services, as prescribed by • Accept or refuse treatment to the extent your physician, will begin. permitted by law and to be informed of the • Receive information about your condition, consequences of such action, which may include treatment, and when and how services will be termination of Coram services. provided before care is provided to allow you to • Decline participation, revoke consent or disenroll give informed consent. in the patient management program at any time. • Considerate and respectful care regardless of • Have your property and person treated with race, religion, gender, national origin, age, medical dignity by all Coram team members. condition, sexual preference or payment source.

Coram Patient Resource Guide 21 • Be free from physical and mental abuse and/ As a Patient, you have the responsibility to: or neglect. • Remain under a physician’s care while receiving • Speak to a health care professional. services and notify Coram of any change of • Know the name, function and qualifications of all physicians. personnel who provide healthcare services to you • Provide a Coram clinician with your complete, and the name of the person responsible for the accurate health history and notify Coram of any coordination of your care. changes in your medical condition. • Be informed of the identity and job title of the staff • Provide a safe home environment in which your members of the pharmacy providing services care can be given. to you and to speak to a supervisor of the staff • Notify Coram of any change in address or phone member if requested. number. • Make decisions about advance directives and • Sign the required consents and releases for to be informed of Coram’s policy to honor those insurance billing. decisions. • Provide Coram with all requested insurance and • Express dissatisfaction with equipment, financial records. Coram is to be notified of any supplies or services provided by Coram without change in insurance coverage. fear of reprisal. • Participate actively in your care by following the • The protection of your medical information plan regarding administration of your prescribed from unauthorized use and disclosure, unless medication, care of your catheter and monitoring otherwise permitted or required by law. of your health status, as instructed by a Coram • Receive a Notice of Coram’s Privacy Practices, clinician and prescribed by your physician. which describes how medical information about • Work with your healthcare team to identify the you may be used and disclosed to carry out desired outcomes of your treatment. treatment, payment or healthcare operations and for other purposes that are permitted by law. • Advise Coram if you are are not willing to follow your established care plan/services and accept • Participate in discussions concerning ethical the consequences of any refusal of treatment or issues related to your care. decision to disregard the agreed upon plan of care. • Receive an initial and ongoing assessment • Treat Coram personnel with respect and regarding the existence of pain, as well as a consideration. timely response to any symptoms of pain, with appropriate and adequate treatment by your • Advise Coram when you are unable to keep healthcare team. an appointment, when you are unavailable (out‑of‑town, on vacation, etc.) while on service, • Complain, without being subject to discrimination and when you are admitted to a hospital. or reprisal, to your state Department of Health if you are not satisfied with Coram’s response to • Contact Coram if you acquire an infectious your concerns. disease during the time you are receiving services, except where exempt by law. • Receive information regarding our policies and procedures. • Provide Coram with a copy of any written advance directives. • Be given reasonable notice regarding anticipated termination of services or plans to transfer to • Advise Coram of any problems or another provider, and participate in that discharge dissatisfaction with our care without fear of or transfer process. discrimination or reprisal. • Examine, review, restrict, amend and • Notify your treating provider of your participation request a copy of your medical records and in the patient management program. to authorize another individual to examine, review, restrict, amend and request a copy of your medical records. • Receive information and know about the philosophy and characteristics of the Coram patient management program.

Coram Patient Resource Guide 22 Medicare Prescription Drug Coverage and Your Rights

Your Medicare Rights health could be seriously harmed by waiting up to 72 hours for a decision. Be ready to tell your You have the right to request a coverage Medicare drug plan: determination from your Medicare drug plan if you disagree with information provided by the • The name of the prescription drug that was not pharmacy. You also have the right to request a filled. Include the dose and strength, if known. special type of coverage determination called an • The name of the pharmacy that attempted to fill “exception” if you believe: your prescription. • you need a drug that is not on your drug plan’s • The date you attempted to fill your prescription. list of covered drugs. The list of covered drugs is called a “formulary;” If you ask for an exception, your prescriber will • a coverage rule (such as prior authorization or a need to provide your drug plan with a statement quantity limit) should not apply to you for medical explaining why you need the off-formulary or non- reasons; or preferred drug or why a coverage rule should not apply to you. • you need to take a non-preferred drug and you want the plan to cover the drug at the preferred Your Medicare drug plan will provide you with a drug price. written decision. If coverage is not approved, the plan’s notice will explain why coverage was denied What you need to do and how to request an appeal if you disagree with the plan’s decision. You or your prescriber can contact your Medicare drug plan to ask for a coverage determination by Refer to your plan materials or call 1-800-Medicare calling the plan’s toll-free phone number on the for more information. back of your plan membership card, or by going to your plan’s website. You or your prescriber can OMB Approval No. 0938-0975 request an expedited (24 hour) decision if your Form CMS -10147 (Approved 09/30/2014)

Centers for Medicare & Medicaid Services (CMS) Medicare Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) Supplier Standards

NOTE: This is an abbreviated version of the supplier • An authorized individual (one whose signature standards every Medicare Durable Medical is binding) must sign the application for billing Equipment, Prosthetics, Orthotics and Supplies privileges. (DMEPOS) supplier must meet in order to obtain • A supplier must fill orders from its own inventory, and retain their billing privileges. These standards, or must contract with other companies for the in their entirety, are listed in 42 C.F.R. 424, sec purchase of items necessary to fill the order. A 424.57(c). supplier may not contract with any entity that is • A supplier must be in compliance with all currently excluded from the Medicare program, applicable Federal and State licensure and any State healthcare programs, or from any regulatory requirements and cannot contract other Federal procurement or non procurement with an individual or entity to provide licensed programs. services. • A supplier must advise beneficiaries that they • A supplier must provide complete and accurate may rent or purchase inexpensive or routinely information on the DMEPOS supplier application. purchased durable medical equipment, and of Any changes to this information must be reported the purchase option for capped rental equipment. to the National Supplier Clearinghouse within • A supplier must notify beneficiaries of warranty 30 days. coverage and honor all warranties under Coram Patient Resource Guide 23 applicable state law, and repair or replace free of • A supplier must disclose to the government any charge Medicare covered items that are under person having ownership, financial, or control warranty. interest in the supplier. • A supplier must maintain a physical facility on an • A supplier must not convey or reassign a supplier appropriate site. This standard requires that the number; i.e., the supplier may not sell or allow location is accessible to the public and staffed another entity to use its Medicare billing number. during posted hours of business. The location • A supplier must have a complaint resolution must be at least 200 square feet and contain protocol established to address beneficiary space for storing records. complaints that relate to these standards. A • A supplier must permit CMS, or its agents to record of these complaints must be maintained at conduct on‑site inspections to ascertain the the physical facility. supplier’s compliance with these standards. • Complaint records must include: the name, The supplier location must be accessible to address, telephone number and health insurance beneficiaries during reasonable business hours, claim number of the beneficiary, a summary of and must maintain a visible sign and posted the complaint, and any actions taken to resolve it. hours of operation. • A supplier must agree to furnish CMS any • A supplier must maintain a primary business information required by the Medicare statute and telephone listed under the name of the business implementing regulations. in a local directory or a toll free number available through directory assistance. The exclusive use • All suppliers must be accredited by a of a beeper, answering machine, answering CMS‑approved accreditation organization in services or cell phone during posted business order to receive and retain a supplier billing hours is prohibited. number. The accreditation must indicate the specific products and services, for which the • A supplier must have comprehensive liability supplier is accredited in order for the supplier insurance in the amount of at least $300,000 to receive payment of those specific products that covers both the supplier’s place of business and services (except for certain exempt and all customers and employees of the supplier. pharmaceuticals). Implementation date: October If the supplier manufactures its own items, this 1, 2009. insurance must also cover product liability and completed operations. • All suppliers must notify their accreditation organization when a new DMEPOS location • A supplier must agree not to initiate telephone is opened. contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from • All supplier locations, whether owned or contacting a Medicare beneficiary based on a subcontracted, must meet the DMEPOS quality doctor’s oral order unless an exception applies. standards and be separately accredited in order to bill Medicare. • A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered • All suppliers must disclose upon enrollment all items, and maintain proof of delivery. products and services, including the addition of new product lines for which they are seeking • A supplier must answer questions and respond accreditation. to complaints of beneficiaries, and maintain documentation of such contacts. • Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation • A supplier must maintain and replace at date: May 4, 2009. no charge or repair directly, or through a service contract with another company, • A supplier must obtain oxygen from a Medicare‑covered items it has rented to state‑licensed oxygen supplier. beneficiaries. • A supplier must obtain ordering and referring • A supplier must accept returns of substandard documentation consistent with provisions found (less than full quality for the particular item) in 42 C.F.R.424.516(f). or unsuitable items (inappropriate for the • DMEPOS suppliers are prohibited from sharing beneficiary at the time it was fitted and rented or a practice location with certain other Medicare sold) from beneficiaries. providers and suppliers. • A supplier must disclose these supplier standards • DMEPOS suppliers must remain open to the to each beneficiary to whom it supplies a public for a minimum of 30 hours per week with Medicare covered item. certain exceptions.

Coram Patient Resource Guide 24 Advance Directives

An Advance Directive is your way of letting health care providers and your family know your decisions about health care and the right to accept or refuse services, even those that could save or sustain life. It is important that you share and tell your wishes to your family and health care team (e.g., doctor, nurse) and that they are written down. You do not need to have a lawyer to create an advance directive, but you do need to sign it in front of the required witnesses in order for it to be accepted and valid. Your Coram nurse will ask you about your advance directive. He or she may provide information about advance directives if you do not have one. If you have one, your nurse will ask for a copy.

Nondiscrimination and Accessibility Notice (ACA § 1557)

Coram CVS Specialty Infusion services complies If you believe that Coram CVS Specialty Infusion with applicable Federal civil rights laws and Services has failed to provide these services or does not discriminate on the basis of race, color, discriminated in another way on the basis of race, national origin, age, disability, or sex. Coram CVS color, national origin, age, disability, or sex, you can Specialty Infusion Services does not exclude file a grievance with: people or treat them differently because of race, Coram CVS Specialty Infusion Services color, national origina, age, disability, or sex. Grievance Departement Attn: Civil Rights Coordinator Coram CVS Specialty Infusion Services: P.O. Box MC 1234 • Provides certain aids and services, free of charge, Woonsocket, RI 02895 when necessary so that people with disabilities have an equal opportunity to communicate Fax: 1-401-652-9935 effectively with us, such as: You can file a grievance by mail, or by fax.If –– Auxiliary aids and services you need help filing a grievance, the Coram CVS –– Written information in other formats (large Specialty Infusion Services Grievance Department’s print, audio, accesible electronic formats, Civil Rights Coordinator is available to help you. other formats) You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office • Provides language services, free of charge, when for Civil Rights electronically through the Office for necessary to provide meaningful access to people Civil Rights Complaint Portal, available at https:// whose primary language is not English, such as: ocrportal.hhs.gov/ocr/portal/lobby.jsf by mail or –– Qualified interpreters phone at: – – Information written in other languages U.S. Department of Health and Human Services If you need these services, contact Customer Care 200 Independence Avenue SW. toll-free at 1-800-423-1411, 24 hours a day, 7 days a Room 509F, HHH Building week. TTY users should call 711. Washington DC 20201 1-800-368-1019 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs. gov/ocr/office/file/index.html. ©2016 Coram LLC

Coram Patient Resource Guide 25 Get Help in Other Languages If you need help or speak a non-English language, call 1-866-322-Get0984 Help (TTY: in Other 711) Languagesand you will be connected to an interpreter who will assist you at no cost. If you need help or speak a non-English language, call 1-866-322-0984 (TTY: 711) and you will be connected to an interpreter who will assist you at no cost. ENGLISH ATTENTION: If you speak English, language assistance services,ENGLISH free of charge, are available to you. Call 1-866-322-0984 (TTY: 711). ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-866-322-0984 (TTY: 711). SPANISH ATENCIÓN: Si usted habla español, tenemos servicios de asistenciaSPANISH lingüística disponibles para usted sin costo alguno. Llame al 1-866-322-0984 (TTY: 711). ATENCIÓN: Si usted habla español, tenemos servicios de asistencia lingüística disponibles para usted sin costo alguno. Llame al 1-866-322-0984 (TTY: 711). CHINESE 小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 1-866-322-0984CHINESE (TTY: 711). Get Help in Other Languages French小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 creole 1-866-322-0984 (TTY: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd If youVIETNAMESE need help or speak a non-English language, CHÚ Ý: Nếu quý vị nói tiếng Việt, thì có sẵn các dịch vụ trợ giúp ngôn ngữ miễn phí dành cho quý vị. Hãy gọi số 1-866-322- call 1-800-423-1411 (TTY: 711) and you will be pouVIETNAMESE lang ki disponib gratis pou ou. Rele 0984 (TTY: 711). 1-800-423-1411CHÚ Ý: Nếu quý vị (TTY:nói tiếng 711). Việ t, thì có sẵn các dịch vụ trợ giúp ngôn ngữ miễn phí dành cho quý vị. Hãy gọi số 1-866-322- connected to an interpreter who will assist you at 0984 (TTY: 711).

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RUSSIAN BITTE BEACHTEN: Wenn Sie Deutsch sprechen, stehen Ihnen unsere Dolmetscher unter der Nummer 1-866-322-0984 (TTY: 알림: 한국어를 하시는 경우 무료 통역 서비스가ВНИМАНИЕ 준비되어 있습니다:: Если .вы 1-866-322-0984 говорите на русском (TTY:알림 711) языке: 한국어를로 연락주시기,, вамserbisyoTAGALOGтелефону 하시는 будут ng 바랍니다 : бесплатно 경우 1-866-322-0984 tulong 무료. sa 통역 предоставлены wika, 서비스가 ( телетайпnang walang 준비되어: услуги711). bayad, 있습니다 переводчика ay . 1-866-322-0984.. Звоните по (TTY: 711)로 연락주시기 바랍니다. RUSSIAN KOREAN ВНИМАНИЕ: Если вы говорите на Farsi711)русском kostenlos языке zur, Verfügung.вам будут бесплатно предоставлены услуги переводчика. Звоните по телефонуTAGALOG:: 1-866-322-0984 1-866-322-0984 ((телетайп:: 711).711). magagamit Pansinin:FARSI Kung sa iyo.nagsasalita Tawagan TAGALOGka ang ng Tagalog, 1-800-423-1411 mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. Tawagan توجه: اگر .به زبان 바랍니다 فارسی گفتگو می 연락주시기 کنيد، 로(711تسھيالت زبانی :TTY) بصورت رايگان .(711 برای :0984-322-866-1 .شما فراھم می 있습니다телетайп) باشد. با 경우 по телефону(TTY: 무료 711) 통역 :1-866-322-0984 서비스가1-866-322-0984 준비되어 تماس بگيريد.Звоните 하시는 .تماس بگيريدВНИМАНИЕ: Если вы говорите на русскомKOREAN языке, вам будут бесплатно предоставлены услуги переводчика알림: .한국어를 TAGALOG Pansinin: Kung nagsasalita ka ng Tagalog, mga serbisyo(TTY:ARABICang 1-866-322-0984ng 711). tulo ng sa wika, (TTY: nang Pansinin:711). walang bayad,Kung nagsasalita ay magagamit ka ng saFARSI Tagalog, iyo. Tawagan mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. Tawagan телефону: 1-866-322-0984 (телетайп: 711).알림 : 한국어를 하시는 경우 무료 통역 서비스가 준비되어TAGALOG 있습니다 . 1-866-322-0984 (TTY: 711)로 연락주시기 바랍니다. توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با مالحظة: إذا كنت 1411-423-800-09841-322-866-1 تتحدث (711 العربية، :TTY) تتوفر تماس خدمات بگيريد. تماس المساعدة بگيريد .اللغوية .(711 مجان أجلك:TTY). اتصل بالرقم 0984ang 1-866-322-0984-322-866-1 (من الھاتف النصي: ang 1-866-322-0984 (TTY: 711). .(711 Pansinin: Kung nagsasalita ka ng Tagalog, mgaARABIC serbisyo ng tulong sa wika, nang walangPansinin: bayad, ay Kung magagamitTAGALOG nagsasalita sa iyo. ka Tawaganng Tagalog,ARABIC mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. Tawagan ang 1-866-322-0984 (TTY: 711). Russian RUSSIAN مالحظة: إذا كنت تتحدث Tawagan العربية، .sa iyo تتوفر خدمات ay magagamit المساعدة اللغوية,bayad مجان walang أجلك. nang اتصل ,wika بالرقم ng tulong sa مالحظة:: 0984-322-866-1 إذاserbisyoإذا( من كنت mga الھاتف تتحدث ,Tagalog النصي: ngالعربية،العربية، ka 711).تتوفر خدمات .(nagsasalita 711 المساعدةالمساعدة:Kung (TTY اللغوية :Pansininمجان أجلك.. 0984-322-866-1 اتصل angبالرقم 0984-322-866-1 ((من الھاتف النصي :: ARABIC .(711.(711 TAGALOG FRENCHВНИМАНИЕ CREOLE: Если вы говорите на русском языке, вам будут бесплатно предоставлены услуги переводчика. Звоните по angng sa1-866-322-0984 wika, nang walang (TTY: bayad, 711).RUSSIAN ay magagamit sa iyo. Tawaganمالحظة:tulo إذا ng كنت serbisyoتتحدث mga العربية، تتوفر ,ng Tagalog خدمات ka المساعدة nagsasalita اللغوية Kungمجان أجلكPansinin: .RUSSIANاتصل بالرقم 0984-322-866-1 (من الھاتف النصي: 711). ВНИМАНИЕ: Если вы говорите на русском языке, ATANSYON:телефонувам будут: бесплатно1-866-322-0984 Si w pale предоставленыKreyòl (телетайп Ayisyen,: genуслуги711). sèvis переводчика èd pou lang. Звонитеki disponib по gratis pou ou. Rele 1-866-322-0984 (TTY: 711). RUSSIAN ang FRENCH1-866-322-0984 CREOLE (TTY: 711). RUSSIAN FRENCHВНИМАНИЕ CREOLE: Если вы говорите на русском языке, вам будут бесплатно предоставлены услуги переводчика. Звоните по телефону: 1-866-322-0984 (телетайп: 711). FRENCHВНИМАНИЕ CREOLE: Если вы говорите на русском языкеATANSYON:, вам будут Si w бесплатно pale Kreyòl предоставлены Ayisyen, genВНИМАНИЕ sèvis услуги èd pouRUSSIAN переводчика: Если lang выki disponibdisponibговорите. Звоните gratisgratis наATANSYON: по русском pou pouтелефону ou.ou. языке ReleRele Si: 1-866-322-0984 w1-866-322-09841-866-322-0984, вамpale будут Kreyòl бесплатно Ayisyen, ( телетайп(TTY:(TTY: 711).711).gen предоставлены: 711).sèvis èd pou langуслуги ki disponib переводчика gratis. pouЗвоните ou. Rele по 1-866-322-0984 (TTY: 711). ВНИМАНИЕ : Если вы говорите на русском языке, вам будут бесплатно предоставлены услуги переводчика. Звоните по ATANSYON:телефону: 1-866-322-0984 Si w pale Kreyòl ( телетайпAyisyen, gen: 711). sèvisRUSSIAN èd pou lang ki disponib gratis pou ou. Releтелефону 1-866-322-0984: 1-800-423-14111-866-322-0984FRENCHARABIC (TTY: 711). (телетайп : 711). телефонуATTENTION: 1-866-322-0984 : Si vous parlez (телетайп français,: 711). des services gratuits d’interprétation sont à votre disposition. Veuillez appeler le 1-866-322- مالحظة: إذا كنت تتحدث العربية، تتوفر خدمات المساعدة اللغوية по مجان أجلك. Звоните .اتصل بالرقم 0984FRENCH услугиARABIC переводчика-322-866-1 (من الھاتف предоставлены النصي: ВНИМАНИЕFRENCHARABIC: Если вы говорите на русском языке , вам будут.(711 бесплатно телефону: 1-866-322-0984 (телетайп: 711). 0984 (TTY: 711). appeler le 1-866-322- مالحظة: إذا Veuillez كنت تتحدث .disposition العربية،à vo treتتوفر sont خدمات المساعدة اللغوية d’interprétation مجان أجلك.gratuits -322--322-اتصل 866services-1 بالرقمfrançais, appelerappeler des lele 1-866 0984-322-866-1 (مالحظةparlez:VeuillezVeuillez من إذا vousكنت الھاتف disposition. : Siتتحدث.disposition النصي : vovotretre العربية، àà.(711 تتوفرsontsont ATTENTION خدمات المساعدة d’interprétationd’interprétation اللغوية مجان gratuitsgratuits Arabic أجلك. rvicesrvicesاتصلARABIC seبالرقمparlez français, des 0984-322-866-1 (من Si vous : الھاتف النصي: FRENCHARABIC ATTENTION.(711 ARABIC مالحظة: إذا كنت تتحدث العربية، تتوفر خدمات المساعدة اللغوية مجان أجلك. .(711 اتصل :TTY) بالرقم appeler) 1-866-322-0984CREOLE le 1-866 0984-322- من الھاتف FRENCHمالحظة:Veuillez إذا النصي: كنت 711).تتحدث.votre dispositionالعربية، à تتوفر sont خدمات المساعدة d’interprétation.(711 اللغوية مجان:gratuits (TTY أجلك. rvices0984اتصل se بالرقم0984parlez français, des-322-866-1 (من Si vous :الھاتف النصي: ATTENTION.(711 Zadzwo ń pod numer 1-866-322- مالحظة: إذا .zykowaكنت ję تتحدث pomoc العربية، łatnaتتوفر bezp خدمات jest المساعدة ępnaاللغوية dost مجان أجلكpo .polsku اتصل cychبالرقم Dla1-800-423-14111-866-322-0984 osób mówią (من الھاتف :UWAGA النصي: ARABIC .(711 0984 (TTY: 711). FRENCH CREOLE ATANSYON:POLISH Si w pale KreyòlFRENCH Ayisyen, CREOLE gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-322-0984 (TTY: 711). مالحظة: إذا كنت تتحدث العربية، .(711تتوفر خدمات :TTY) المساعدة0984 اللغوية مجان أجلك. اتصل بالرقم 0984-322-866-1 (من الھاتف النصي: 711). FRENCH CREOLE POLISHATANSYON: UWAGA:UWAGA: Si w DlaDlapale osóbosób Kreyòl mówimówi Ayisyen,ących genpoFRENCH polsku sèvis èddost CREOLE pouępna lang jest ki bezpdisponibłłatna gratis pomocPOLISH pouATANSYON: ję zykowa.ou. UWAGA: Rele Zadzwo 1-866-322-0984 Si Dla w paleosóbń podpod Kreyòl mówi numernumer ą(TTY: Ayisyen,cych 1-866-322-1-866-322- 711).po polskugen sèvis dost èdępna pou jest lang bezp ki disponibłatna pomoc gratis ję pouzykowa. ou. Rele Zadzwo 1-866-322-0984ń pod numer (TTY:1-866-322- 711). FRENCH CREOLE POLISHATANSYON: UWAGA: Si w Dla pale osób Kreyòl mówi Ayisyen,ących pogen polsku sèvis0984 dostèd (TTY:pouępna lang 711).jest ki bezp disponibłatna gratispomoc pou językowa. ou. ReleATANSYON: Zadzwo 1-866-322-0984ńATANSYON:FRENCH podSi w numer pale (TTY: Kreyòl Si1-866-322- w 711). pale Ayisyen, Kreyòl0984 Ayisyen,gen (TTY: sèvis 711).gen èd sèvis pou èd lang pou ki lang disponib ki disponib gratis gratis pou pou ou. ou.Rele Rele 1-866-322-0984 1-866-322-0984 (TTY: (TTY: 711). FRENCH CREOLE PORTUGUESE ATENÇÃO: Se fala português, estão disponíveis serviços gratuitos de assistência linguística na sua língua. 0984 (TTY: 711). ATANSYON: FRENCH Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki ATTENTION disponib gratis : Sipou vous ou. Releparlez 1-866-322-0984FRENCH français, des (TTY: services 711). gratuits d’interprétation sont à votre disposition. Veuillez appeler le 1-866-322- Telefone para 1-866-322-0984 (TTY: 711). 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ChiamiChiami 1-866-31-866-322- ITALIANPOLISH POLISH UWAGA:0984 (TTY: Dla 711).osób mówiącychATTENZIONE: po polsku dostSe leiępna parla jest italiano, bezpłatna sono pomoc disponibili językowa. servizi Zadzwo gratuiti ńdi pod assistenza numer 1-866-322- linguistica nella sua lingua. Chiami 1-866-322- 0984 (TTY: 711). POLISH0984 UWAGA: (TTY: 711). Dla osób mówiących po polsku dostępna jest PORTUGUESE bezpłatna pomoc ATENÇÃO: językowa. Zadzwo Se falań pod português, numer 1-866-322- estão disponíveis serviços gratuitos de assistência linguística na sua língua. ATTENZIONE: Se lei parla italiano, sono disponibili0984 (TTY: servizi 711). gratuiti di assistenza linguistica0984 nella (TTY: sua lingua. 711). Chiami 1-866-322-0984 (TTY: 711). PORTUGUESE ATENÇÃO: Se fala português, estãoJAPANESETelefone disponíveis para servお知らせ 1-866-322-0984iços gratuitos: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれまPORTUGUESE de(TTY: assistência 711). 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Telefone paraお知らせ 1-866-322-0984日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま (TTY: 711). 0984 (TTY: 711)までお問い合わせ下さい。 す。電話番号 PORTUGUESE ATENÇÃO: Se fala português,PORTUGUESEJAPANESE estão disponíveis ATENÇÃO: serv ::Se iços fala gratuitos português, de estão assistênciaPORTUGUESE disponíveis linguísticaTelefone serv ATENÇÃO:iços para na gratuitos sua 1-866-322-0984 língua.Se de fala assistênciaJAPANESE português,Telefone (TTY: linguística 711). estãoお知らせ para na1-866-322-0984disponíveis sua: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま língua. serv iços1-866-322-(TTY: gratuitos 711). de assistência linguística na sua língua. す。電話番号1-866-322- までお問い合わせ下さい。 CoramITALIAN Patient Resource Guide 26 JAPANESETelefone para お知らせ 1-866-322-0984: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま (TTY: 711). Telefone0984 para (TTY: 1-866-322-0984 711)までお問い合わせ下さい。 (TTY: 711). Telefone す。電話番号 para 1-866-322-09841-866-322- (TTY:0984 711). (TTY: 711)までお問い合わせ下さい。 ITALIAN ITALIANATTENZIONE: Se lei parla italiano, sono disponibili servizi gratuiti di assistenza linguistica nella sua lingua. Chiami 1-866-322- 0984 (TTY: 711)までお問い合わせ下さい。 GERMAN ITALIAN ITALIAN ITALIANGERMANATTENZIONE: Se lei parla italiano, sono ITALIANdisponibili serviziATTENZIONE:0984BITTE (TTY:gratuiti BEACHTEN: 711). diSe assistenza lei parla Wenn italiano, SielinguisticaATTENZIONE: Deutsch sono dinellasponibili sprec Sesuahen, leiservizi lingua. parla stehen gratuiti Chiamiitaliano, Ihnen di assistenza1-866-3 sono unsere di22-sponibili Dolmetscherlinguistica servizi nella unter gratuitisua lingua.der di Nummer assistenza Chiami 1-866-31-866-322-0984 linguistica22- nella (TTY: sua lingua. Chiami 1-866-322- 0984 (TTY: 711). 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JAPANESE お知らせ: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま0984 (TTY: 711)までお問い合わせ下さい。 す。電話番号 1-866-322- توجه: اگر به زبان فارسی گفتگو می -322-866-1کنيد، تسھيالت す。電話番号 زبانی بصورت رايگان برای شما فراھم می باشد. با 。TTY:0984 711) (TTY: 1-866-322-0984 711)までお問い合わせ下さい) تماس -322-866-1بگيريد日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま. :تماس お知らせبگيريد .JAPANESE お知らせ: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれまFARSI0984 (TTY: 711)までお問い合わせ下さい。JAPANESE す。電話番号 0984FARSI (TTY: 711)までお問い合わせ下さい。 FARSI 0984 (TTY: 711)までお問い合わせ下さい。 GERMANまでお問い合わせ下さい。 توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد . با توجه:: اگر به زبان 0984-322-866-1فارسی (711گفتگو می :TTY) کنيد،کنيد، تماس تسھيالت بگيريد. زبانی تماس بصورت بگيريد.رايگان برای شماشما فراھم می (GERMAN711 باشد.. بابا :TTY:(TTY: 711)711) 1-866-322-09840984 (TTY) تماس بگيريد.. تماس بگيريد.. 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توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با توجه: اگر به زبان 0984-322-866-1 فارسی توجه(711: اگر گفتگو به :TTY)می زبان کنيد،تماس فارسی بگيريد. تسھيالتگفتگو می تماس زبانی کنيد، بگيريد.بصورت تسھيالت زبانیرايگان برای بصورت شما رايگان فراھم برایمی شما باشد . بافراھم می باشد. باTTY: 1-866-322-0984 711) 1-866-322-0984 FARSI)(711 تماس :TTY) بگيريدتماس . بگيريدتماس. تماس بگيريد.بگيريد. FARSI توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با توجه: 0984-322-866-1اگر به (711 زبان :TTY)فارسی تماس گفتگو می بگيريد. کنيد، تماس تسھيالت بگيريد.زبانی بصورت رايگان برای شما فراھم می باشد. با TTY: 711) 1-866-322-0984) تماس بگيريد. تماس بگيريد.

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1. https://www.inogen.com/blog/10-home-oxygen-safety-tips/, accessed September 5, 2019. 2. http://www.redcross.org/get-help/how-to-prepare-for-emergencies/types-of-emergencies/fire, accessed September 5, 2019. 3. https://www.ncoa.org/resources/falls-prevention-conversation-guide-caregivers/, accessed September 5, 2019. *Coram uses a combination disposal system that ensures incineration of contaminated sharps and other supplies contaminated with hazardous drugs. †MinuteClinic® employs physician assistants in select states. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care provider about this information and any health- related questions you have. Coram assumes no liability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. ©2019 Coram LLC. All rights reserved. 75-49687A 110519