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Your First Name*

Your Last Name*

Your E-mail Address*

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Your Primary Phone Number

Your Mobile Phone Number

Your Work Phone Number

Birthdate*

Gender*

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Patient's First Name*

Patient's Last Name*

Birthdate*

Email Address*

Cardholder ID*

Where can I find my Cardholder ID?

Enter Profile Add Address Password & Security

Add Address

Your Primary Address should be the address associated with your health insurance and credit card billing information. This is different from your shipping address(es).

Address Line 1*

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City*

State*

Zip Code*

Enter Profile Add Address Password & Security

Password & Security

Please enter your password, and select your security questions and answers.

Your password must contain:

At least 8 characters
1 uppercase letter
1 lowercase letter
1 number

Note: Password cannot be the same as or contain user ID. Special characters such as '&' may be used. Previous passwords cannot be reused. Passwords are case-sensitive. Passwords can only be changed once every 24 hours.

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Patient Consent

Allows Edgepark to discuss your order with the necessary parties, such as your doctor and health insurance provider, and gives us permission to bill your health insurance provider for your supplies.

Statement to Permit Payment of Insurance Benefits to Provider, Physician, and Patient I request that payment of authorized Medicare and/or private insurance benefits be made either to me or on my behalf to RGH Enterprises, Inc. d/b/a Edgepark Medical Supplies (Edgepark) for any services furnished to me by Edgepark. I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services and/or my private insurance, and its agents, any information needed to determine these benefits for related services.

I understand that Edgepark reserves the right to review all agreements on an individual basis to determine the continued acceptance of assignment for Medicare and/or any other medical insurance companies. In the event medical necessity no longer exists or my payer no longer deems my supplies to be covered, I understand I must return the unopened, reusable supplies to Edgepark so they may refund my insurance. I agree to call before returning the supplies.

I acknowledge receipt and understanding of my Patient/Client Bill of Rights, Medicare DMEPOS Supplier Standards, and Notice of Privacy Practices that I received as part of my supply order and understand that I may also view a copy of these documents at www.edgepark.com. I also acknowledge that I have received and/or will receive training on the use of all products I order from Edgepark. In addition, I agree that Edgepark may contact me in the future, via telephone, email, instant messaging, mail or other means of communication, regarding ordering medical supplies. Form EP PA, Version 0813

I have read and agree to the Patient Consent authorization.

Marketing Consent

Receive special offers from Edgepark

Don't Miss Out on Product Samples and Other Important Information About Your Supplies! Edgepark provides our customers with a variety of order reminders, product samples and educational information. However, federal regulations prohibit us from sending many of these important benefits to you unless you authorize Edgepark, in writing, to send them. It only takes a minute to electronically sign and date this form.

This authorization does not affect Edgepark's ability to send "transactional communications," such as those notifying you of product recalls or requesting information prior to order shipment, or communications for which Edgepark does not receive a payment. This authorization will expire 18 months following the last date you have ordered from Edgepark, or at any time you choose to revoke this authorization by calling 1.800.321.0591, ext. 3151. Edgepark may not condition your treatment, payment, enrollment or eligibility for benefits on whether you choose to sign this authorization.

Edgepark does not provide your personal information to our manufacturer partners; however, we may provide your information to a third party printer/mailing house for the purposes of sending you the communications as described above. By law, we are required to notify you that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and thus no longer protected by the Health Insurance Portability and Accountability Act (HIPAA).Form EP MC, Version 0819

I authorize Edgepark to use or disclose my protected health information in order to communicate with me regarding treatment options or other health-related products or services, for which Edgepark may receive a payment.

Terms and Conditions

Edgepark Medical Supplies

Terms and Conditions of Electronic Account

Patient Access

Edgepark Medical Supplies is pleased to make available to you on-line access to portions of your account through Edgepark.com . By logging in to Edgepark.com, you agree to the following Terms and Conditions, as the same may be modified, amended or replaced from time-to-time without notice to you. If you are accessing the Edgepark.com Website on behalf of another party, these terms and conditions shall apply to such access.

1. Security and Usage Guidelines for Edgepark.com.

Edgepark.com is an Internet-based environment through which you may receive certain confidential medical information about yourself, perform certain self-service functions and send and receive secure messages to or from certain RGH Enterprises, Inc. dba Edgepark Medical Supplies (collectively, “Edgepark”). NEVER SEND ANY MESSAGES REQUIRING URGENT OR EMERGENCY ATTENTION USING EDGEPARK.COM. FOR ALL URGENT OR EMERGENCY MEDICAL MATTERS, IMMEDIATELY CONTACT YOUR HEALTH CARE PROVIDER’S OFFICE BY PHONE, GO TO AN EMERGENCY ROOM, OR CALL 911.

Do not share your Edgepark.com username, password or security questions and answers with anyone. The individual username and password you choose when you first login to Edgepark.com are the keys to protecting the confidentiality of your information. You are responsible for preventing disclosure of your username, password and security questions and answers. Edgepark is not liable for any damages that result from your failure to keep this information secure. You can change your password and security questions and answers at any time and should change your password if you feel that your security has been compromised. Your username and password are unique codes that identify you in the Edgepark computer system. Inquiries that you make via Edgepark.com will be logged with your identity.

You are required to provide us with your personal e-mail address when activating your Edgepark.com account and to keep your e-mail address current at all times. You may receive other e-mail notices and messages from time to time from Edgepark. You understand that this means that any person with access to the e-mail address you designate in Edgepark.com may see these notifications and messages. Depending on the e-mail account you designate, this may include your employer, your spouse or anyone else able to access your account.

2. Your Responsibilities

By accessing or using Edgepark.com, you agree to be bound by all these Terms and Conditions. It is important to review these Terms and Conditions periodically because they may be modified at any time. You agree to be bound by any and all such modifications as of the time that they are posted. You agree that Edgepark.com is a communication service offered as a convenience to patients of Edgepark. You are solely responsible for any sharing of personal or confidential information, including health information concerning your health care condition that you intentionally or unintentionally communicate to others.

You will not post any offensive or abusive material on the Edgepark.com site or send any abusive or offensive messages through Edgepark.com.

You understand that the electronic record from which the information in Edgepark.com is generated and the information in Edgepark.com is the property of Edgepark.

3. Privacy

The privacy of your health information is very important to us. Edgepark will use and disclose your health information in accordance with our Notice of Privacy Practices, in order to provide you with health care services and as needed for Edgepark's treatment, payment and operations purposes. Please review the Notice of Privacy Practices for an explanation of how, when, and why we use and disclose your health information.

4. Discontinuing Use of Edgepark.com

You may discontinue your use of Edgepark.com at any time by contacting Edgepark.

Your use of Edgepark.com may be discontinued by Edgepark at any time for any reason or no reason. Without limiting the foregoing, your use of Edgepark.com will be discontinued if you have violated these Terms and Conditions or you have abused or misused Edgepark.com. If your use of Edgepark.com has been discontinued, reasonable efforts will be made to notify you that your use has been discontinued.

5. Minor Eligibility

An individual must be 18 years or older to request access to health information in Edgepark.com. Parents or guardians of minor children may request proxy access to the minor child’s health information through Edgepark.com by following the terms outlined in the “Proxy Access” section of these Terms and Conditions.

6. Proxy Access

You may request proxy access to the account and health information of an individual who is either under the age of 18 years (a minor) or incompetent through Edgepark.com by completing the appropriate Proxy Access forms and submitting them to Edgepark. Such access may be granted to individuals who are a parent, guardian, or healthcare proxy of or for the minor or incompetent patient, as defined under applicable law. If the proxy’s legal relationship with the minor or incompetent patient changes, either you or the proxy must inform Edgepark immediately and proxy access may be discontinued based on this change of relationship. Your proxy access to the health information of a minor through Edgepark.com will be automatically terminated on the minor’s eighteenth (18th) birthday.

You may request proxy access to another adult’s or an emancipated minor’s health information through Edgepark.com by completing the appropriate Proxy Access form and submitting it to Edgepark. Both the requesting adult and the person whose health information will be accessed will be required to sign these Proxy Access forms.

7. Copyright and Trademarks

All content included in Edgepark.com, including but not limited to text, photographs, graphics, icons, images, artwork, names, logos, trademarks, service marks and data (the “Content”) in any form including the compilation thereof, are protected by United States and international copyright law and conventions. The Content includes both Content owned or controlled by Edgepark as well as Content owned or controlled by third parties and licensed to Edgepark. Except as set forth below, direct or indirect reproduction of the Content, in whole or in part, by any means, is prohibited without Edgepark’s express, written consent.

The words “Edgepark Medical Supplies” and its associated corporate logos are the trademarks and service marks of RGH Enterprises. You are prohibited from using any trademark, service mark or logo displayed on the Edgepark.com without the express permission of Edgepark.

8. Site Access and Licenses

Edgepark grants to you a limited license to use the Edgepark.com Web site and the associated services in accordance with these Terms and Conditions. This license expressly excludes, without limitation, any reproduction, duplication, sale, resale or other commercial use of the Web site and the associated services, making any derivative of the Web site or the associated services, and the collection and use of user e-mail addresses or other user information, including, without limitation, health information or any data extraction or data mining whatsoever.

9. Security and Confidentiality

When using Edgepark.com information will be transmitted over a medium that is beyond the control of Edgepark. YOU HEREBY EXPRESSLY ASSUME THE SOLE RISK OF ANY UNAUTHORIZED DISCLOSURE OR INTENTIONAL INTRUSION, OR OF ANY DELAY, FAILURE, INTERRUPTION, OR CORRUPTION OF DATA OR OTHER INFORMATION TRANSMITTED IN CONNECTION WITH THE USE OF THIS SERVICE.

10. Links to Third Party Sites

The Edgepark.com Web site may contain links to Web sites operated by third parties. The links are provided for your convenience only. Edgepark does not control or endorse the information on such Web sites, nor are they responsible for the content and performance of these sites. Edgepark does not operate, control, or endorse any information, products, or services provided by third parties through the Internet. Use of other sites is strictly at your own risk including, but not limited to, any risks associated with destructive viruses.

11. No Warranties; Limitation of Liability

TO THE FULLEST EXTENT PERMISSIBLE UNDER ANY APPLICABLE LAW, RULE OR REGULATION, EDGEPARK IS PROVIDING THE SERVICES AND INFORMATION AVAILABLE ON THE EDGEPARK.COM WEB SITE “AS IS” AND WITHOUT REPRESENTATION OR WARRANTY, AND HEREBY DISCLAIM ALL WARRANTIES OF ANY KIND, EXPRESSED OR IMPLIED, WRITTEN OR ORAL, INCLUDING, BUT NOT LIMITED TO, ANY WARRANTY OF MERCHANTABILITY, SUITABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, SECURITY, ANY WARRANTY THAT AVAILABILITY OR OPERATION WILL BE UNINTERRUPTED OR ERROR FREE, AND/OR ANY WARRANTY TO PROVIDE ADEQUATE TECHNICAL SUPPORT.

To the fullest extent permitted by law, Edgepark shall not be liable under any circumstances for special, indirect, incidental, punitive or consequential damages that you may incur as a result of Edgepark’s actions or omissions, even if it was aware of the possibility for such damages. In no circumstance shall Edgepark be liable to you for any act or failure to act by any third party. If you are dissatisfied with Edgepark.com or these Terms and Conditions, your sole and exclusive remedy is to terminate your access to Edgepark.com. If any portion of the foregoing limitation is found to be void or unenforceable, the liability of Edgepark for any damages resulting from or relating to the use of Edgepark.com shall be limited to $10.00.

12. Governing Law; Venue

These Terms and Conditions shall be governed by and construed under the laws of the State of Ohio, without reference to the conflict of laws or principles thereof. The parties hereby irrevocably agree that all actions or proceedings in any way, manner or respect arising out of or from, or related to these Terms and Conditions or the services referenced herein shall be litigated only in courts having situs within Summit County, Ohio. You may not assign any of your rights or obligations under these terms and conditions to any third party without the express, prior written consent of Edgepark. Any attempted assignment in violation hereof shall be null and void and of no effect whatsoever. In connection therewith, the parties hereby consent and submit to the jurisdiction of any local, state or federal court located within said county and state and hereby waive any right the parties may have to transfer or change the venue of any such litigation.

13. Miscellaneous

If any provision of these Terms of and Conditions is found to be invalid or unenforceable by a court of competent jurisdiction, such provision shall be reformed only to the extent necessary to make it enforceable and the other terms of this agreement shall remain in full force and effect. You cannot transfer your rights or obligations under the Terms and Conditions to anyone without the prior written consent of Edgepark. The failure by Edgepark to enforce any provision of these Terms and Conditions does not waive Edgepark’s right to enforce the same provision in the future. Any headings contained in these Terms and Conditions are for informational purposes only, but are not, themselves, enforceable provisions of these Terms and Conditions. We may modify these terms and conditions, other terms and materials referenced in this document, set forth on the Edgepark.com Web site or the content of Edgepark’s Web site at any time. For this reason, you should review these Terms and Conditions on the Edgepark.com Web site periodically.

I have read and agree to these Terms and Conditions*

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