Proof of Delivery Form

DME Proof of Delivery & Patient Instruction

Home Environment/Safety Assessment

Equipment

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)

Sign Here
Sign Here
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