DME Proof of Delivery Patient Instruction Medical Logistics Solutions Name(Required) Date MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Initial Delivery Follow-up Phone(Required)Phone(Required)Alternate Contact:(Required)OTHER HOME CARE SERVICES Phone(Required)EQUIPMENTMake & Model Lot/Serial # Amount Billed to Insurance : Approximate Co-Pay TYPE OF PRODUCT Lumbar Brace LSO Type 1 L-O648 Lumbar Brace LSO Tpye lll L-O648 Lumbar Belt Brace L-O642 Cervical Hard Collar L-O172 L-O174 L-O180 Cervical Soft Collar L-O120 Small Medium Large Other ADDITIONAL INSTRUCTIONSThe following has been given to and/or discussed with the patient/caregiver Rights & Responsibilities Warranty Information Service availability (Scope of Services) Capped Rental Purchase Letter (signed) Privacy Notice infection Control Tips/ Equipment instructions Medicare Supplier Standards 30 (link) Cleaning & Maintenance of equipment Complaint Protocol: lf you are unhappy with the services provided by this company please call 541-515-6258. 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 I-888-291-5353. ADDITIONAL NOTESFOLLOW UP/DISCHARGE FOLLOW-UP VISIT RECOMMENDED FOLLOW-UP BY PHONE & AS NEEDED Signatures below confirm all applicable information was given to the patient A copy of this form has been given to the patient/caregiver If patient unable to sign; authorized person complete. If person does not live with patient list contact informationPATIENT SIGNATUREPrint name/Relationship/WHY the patient can't sign EMPLOYEE's signatureDate MM slash DD slash YYYY IF THE AUTHORIZED PERSON DOES NOT LIVE WITH THE PATIENT, LIST THEIR ADDRESS/PHONE NUMBER EQUIPMENT WARRANTY INFORMATION FORM Every product sold or rented by our company carries a 1-year manufacturer’s warranty. Medical Logistics Solutions, LLC will notify all Medicare beneficiaries of the warranty coverage, and we will honor all warranties under applicable law. Medical Logistics Solutions, LLC will repair or replace, free of charge, Medicare-covered equipment that is under warranty. In addition, an owner’s manual with warranty information will be provided to beneficiaries for all durable medical equipment where this manual is available. If the item falls outside the manufacturer’s warranty but is still being rented from Medical Logistics Solutions, LLC (i.e. the 13th month), Medical Logistics Solutions, LLC will honor the product for any issues that would have been covered by the manufacturer’s warranty. Medical Logistics Solutions, LLC does not warranty any issues caused by normal wear and tear or patient abuse or neglect. By signing the DME or Plan of care form, I acknowledge I have been instructed and understand the warranty coverage on the product I have received. I received instructions and understand that Medicare defines the ____________________ that I received as being inexpensive or routinely purchased item. FOR INEXPENSIVE OR ROUTINELY PURCHASED ITEMS: • Equipment in this category can be purchased or rented; however, the total amount paid for monthly rentals cannot exceed the fee schedule purchase amount. • Examples of this type of equipment include: Lumbar Braces, Cervical collars, Canes, walkers, crutches, commode chairs, low pressure and positioning equalization pads, home blood glucose monitors, seat lift mechanisms, pneumatic compressors (lymphedema pumps), bedside rails, and traction equipment. • I select the: Purchase Option Rental Option Beneficiary Signature Please sign and return this portion for all items in this category.Date MM slash DD slash YYYY Assignment of Benefits (AOB) My signature and date in the box below authorizes each of the following:1. Assignment of Medicare, Medicaid, Medicare Supplemental or other insurance benefits to Medical Logistics Solutions, LLC for medical supplies and/or medication(s) furnished to me by Medical Logistics Solutions, LLC. 2. Direct billing to Medicare, Medicaid, Medicare Supplemental or other insurer(s). 3. Release of my medical information to Medicare, Medicaid, Medicare Supplemental or other insurers and their agents . 4. Medical Logistics Solution, LLC and/or any of our corporate affiliates to obtain medical or other information necessary in order to process my claim(s), including determining eligibility and seeking reimbursement for medical supplies and/or medication(s) provided. 5. Medical Logistics Solutions, LLC and/or any of our corporate affiliates to contact me by telephone or mail regarding my medical supplies and/or medication(s) order. I agree to pay all amounts that are not covered by my insurer(s) including applicable co-payments and/or deductibles for which I am responsible. Your PhoneSIGN YOUR NAME HERETODAY'S DATE MM slash DD slash YYYY I request that payment of Medicare, Medicaid, Medicare Supplemental or other insurance benefits be made on my behalf to Medical Logistics Solutions, LLC and/or any of our corporate affiliates for any medical supplies and/or medications furnished to me by Medical Logistics Solutions, LLC I authorize any holder of medical information about me to release to Medical Logistics Solutions, LLC my physician(s), caregiver, CMS, its agents and to my primary and/or other medical insurer any information needed to determine or secure eligibility information and/or reimbursement for covered services. I agree to pay all amounts that are not covered by my insurer(s) and for which I am responsible.YOUR MEDICARE #Insurer Other than or in addition to MedicarePolicy # Insurer Phone #Please correct any errors in your name and address below
