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Oxylife Respiratory Services, LLC I,
____________________________________ a customer and patient assigned to OxyLife Respiratory Services, LLC acknowledge that in
accordance to Medicare guidelines described below and your Physicians
prescription, are in acceptance of receiving all related CPAP supplies as
provided in the described schedule.� It
is understood that monthly and quarterly supplies will be delivered via UPS
sent by OxyLife Respiratory Services, LLC and that
the appropriate billing will be issued as the supplies are delivered. |
|
____ |
Nasal Mask
__________ |
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1 per 3
Months |
|
____ |
Nasal Mask
Cushions __________ |
|
2 per Month |
|
____ |
Nasal
Pillows __________ |
|
2 per Month |
|
____ |
Full Face
Mask __________ |
|
1 per 3
Months |
|
____ |
Full Face
Mask Cushions __________ |
|
1 per Month |
|
____ |
Headgear __________ |
|
1 per 6
Months |
|
____ |
Chinstrap __________ |
|
1 per 6
Months |
|
____ |
Tubing __________ |
|
1 per 3
Months |
|
____ |
Filter
Disposable __________ |
|
2 per Month |
|
____ |
Filter Non
Disposable __________ |
|
1 per 6
Months |
|
____ |
Water
Chamber __________ |
|
1 per 6
Months |
|
Note:� Change cushions/pillows every two weeks ����������� Change filter monthly |
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Supplies will be provided monthly in-order to
comply with Medicare and Manufacturers recommended cleaning and disposal
schedules.� |
Patient Acceptance:�
________________________________________� Date:�
______________
OxyLife Respiratory Rep:� ____________________________________� Date:� ______________