Proof of Delivery Form

DME Proof of Delivery & Patient Instruction


Home Environment/Safety Assessment


Equipment


Patient Information & Orientation Guide


Thank you for choosing Matia Mobility. Our goal is to ensure you have the equipment and support necessary to improve your mobility and independence. Please review this information carefully and keep it for your records.

1. Rights & Responsibilities

As a patient, you have the right to:

  • Receive high-quality service and equipment without discrimination.

  • Be informed of the scope of services we provide and any limitations.

  • Participate in the planning of your care and the selection of your equipment.

  • Privacy and confidentiality regarding your personal and medical information.

Your responsibilities include:

  • Providing accurate health information and insurance details.

  • Following the manufacturer’s instructions for equipment use.

  • Notifying us immediately if the equipment is damaged or no longer needed.

  • Meeting any financial obligations related to your equipment.

2. Warranty Information

Matia Mobility honors all manufacturer warranties.

  • New Equipment: Most frames and electronic components are covered under a limited manufacturer warranty for one (1) year.

  • Repairs: Labor performed by our technicians is guaranteed for 90 days.

  • Exclusions: Warranties do not cover damage caused by misuse, accidents, or unauthorized alterations.

3. Service Availability (Scope of Services)

We provide specialized mobility solutions, including evaluation, delivery, fitting, and ongoing maintenance.

  • Hours of Operation: Monday–Friday, 9:00 AM – 5:00 PM Mountain Time.

  • Emergency Service: For equipment failures that pose a safety risk after hours, please call 801-997-1812.

4. Cleaning & Maintenance of Equipment

To ensure the longevity and safety of your device:

  • Cleaning: Wipe down surfaces with a damp cloth and mild detergent. Do not submerge electronic components in water.

  • Inspection: Regularly check for loose bolts, tire pressure, and battery health.

  • Professional Service: We recommend a professional safety check every 12 months.

5. HIPAA Privacy Notice

Your health information is protected by law. We use your information only for treatment, payment, and healthcare operations. You have the right to inspect your records and request a history of disclosures. For a full copy of our Privacy Practices, please contact our Compliance Officer.

6. Infection Control & Equipment Instructions

  • Infection Control: Always wash your hands before and after using your mobility device. If the equipment is shared, disinfect touchpoints (joysticks, armrests) frequently.

  • Instructions: You have been provided with a manufacturer’s user manual. Do not operate this equipment until you have read the manual and received a demonstration from our staff.

7. Medicare Supplier Standards (The “30 Standards”)

As a Medicare-enrolled supplier, Matia Mobility meets the 30 standards established by the Centers for Medicare & Medicaid Services (CMS). These standards ensure we are a legitimate business, provide quality equipment, and honor all warranties. A full list of these standards is available upon request or at CMS.

8. Follow-Up Policy & Process

We are committed to your long-term success. Our follow-up process includes:

  1. Post-Delivery Call: Within 3 days to ensure you are comfortable with the device.

  2. Satisfaction Survey: We may contact you to gather feedback on our service.

  3. Ongoing Support: If your physical condition changes or the equipment requires adjustment, contact us to schedule a re-evaluation.

Additional Instructions


The following has been given to and/or discussed with the patient/caregiver:

Rights & Responsibilities
Warranty Information
Service availability (Scope of Services)
Cleaning & Maintenance of Equipment
HIPAA Privacy Notice
Infection Control Tips/Equipment Instructions
Medicare Supplier Standards 30
Follow Up Policy & Process

Complaint Protocol: Patient / Caregiver: If you are unhappy with the services provided by this company please call (801) 997 – 1812. We will respond within 5 calendar days. In the event your complaint is not resolved to your satisfaction you can contact our accrediting organization The Compliance Team at www.thecomplianceteam.org or by calling 1-888-291-5353.

Follow Up / Discharge


Signatures below confirm all applicable information was given to the patient

(If Patient unable to sign; authorized person complete. If person does not live with patient list contact information)

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