Delivery Receipt Equipment Agreement

Rental Agreement

This is a sample Delivery Receipt for rental of equipment in which the following terms apply:

The Customer Acknowledges receipt of the equipment described, on the service dates indicated, and agrees that title to the equipment shall at all times be and remain in Lessor ("Company"); that this is a transaction of lease only; that the equipment is accepted in its "as is" condition (having been inspected by the undersigned upon delivery); and further, the Customer agrees: to protect the equipment from all loss or damage and remain responsible for it, to release the equipment for pick-up only to a duly authorized representative of the Company, to operate the equipment only in the manner for which it was intended, to refrain from making any repairs to the equipment (but the Customer will notify Company in the event repairs are needed), and to promptly and faithfully pay the stated rental each month (without pro-rate) until the equipment has been returned (it being understood that Company will credit the Customer's account for payments recieved by Company under any medical insurance program or from any third party).

The Customer has been informed and agrees that Company is not a manufacturer of the equipment, and is not responsible for the adequacy of the same nor for any defects in the equipment or which may appear from the use and maintenance thereof; nor shall Company be responsible for any delay or interruption in connection with the delivery or service of the equipment or for any damage whatsoever relating to the use of this equipment. Company has not prescribed the equipmet, and makes no representations with regard to suitability of the equipment for any specific purpose of the Customer, and assumes no liability for any warranties whasoever, expressed or implied. The customer agrees to accept whatever warranties are offered by the manufacturer of the equipment in lieu of any warranties of seller. The Customer irrevocably agrees to indemnify and save Company harmless from and against any claims whatsoever which may be brought by any persons whomsoever arising from the rental, delivery and use of the said equipment.

Sale Agreement

This is a sample Delivery Receipt for sale of equipment in which the following terms apply:

The Customer acknowledges receipt of equipment described, on the date indicated, and agrees that the equipment is accepted in its "as is" condition (having been inspected by the Customer upon delivery). The Customer agrees to pay the stated price for the equipment, it being understood that credit will be given to the Customer's account for payments recieved from any medical insurance program or from any third party.

The Company ("Seller") has not prescribed the equipment, and further makes no warranty whatsoever, expressed or implied, of merchantability or fitness for purpose. On the contrary, the customer has been informed and agrees that they know that Seller is not a manufacturer of the equipment and is not responsible for the adequacy of the same, nor for any defects in the equipment or which may appear from the use and maintenance thereof. The Customer agrees to accept whatever warranties are offered by the manufacturer of the equipment in lieu of any warranties of Seller. Seller is not responsible for any damage whatsoever relating to the sale or use of this equipment.

The Customer irrevocably agrees to indemnify and save seller harmless from and against any claim whatsoever which may be brought by any persons whomsoever arising from the sale, delivery, and use of the equipment.

CMS Supplier Standards

Effective on December 11, 2000

1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
3. An authorized individual (one whose signiture is binding) must sign the application for billing privleges.
4. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or nonprocurement programs.
5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
7. A supplier must maintain a physical facility on an appropriate site.
8. A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier's compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours and must maintain a visible sign and posted hours of operation.
9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or toll free number available through directory assistance. The exclusive use of a beeper, answering machine or cell phone is prohibited.
10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier's place of business and all customers and employees of the supplier. If the supplier manufacturers its own items, this insurance must also cover product liability and completed operations.
11. A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business.
12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery.
13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries.
15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
18. A supplier must not convey or reassign a supplier number, i.e., the supplier may not sell or allow another entity to use its Medicare billing number.
19. A supplier must have a complaint resolution policy protocall established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
21. A supplier must agree to furnish CMS any information required by the Medicare statue and implementing regulations.