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 __________

 

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
            Clean tubing every two weeks

            Change filter monthly

 

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:  ______________