top of page

Patient Acknowledgement Orientation Form

I acknowledge that I have received and understand the following information:


  • My rights as a customer.

  • My responsibilities as a customer.

  • My Communications Form and Perception of Care Survey to voice a complaint or concern.

  • My Delivery contract/Work Order denoting equipment delivered.

  • My Release of Information/Assignment of Benefits.

  • The safe environment of my home and its suitability to the equipment delivered.

  • The safe and proper operation of the equipment delivered.

  • Equipment and supply cleaning procedures.

  • Important telephone numbers, including after-hours information.

  • Received information regarding Emergency Preparedness and Infection Control Training

  • Medicare Supplier Standards.

  • HIPAA Privacy Notice.

  • Web address

  • Other

bottom of page