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 spmedicalsupply.com
Other

EQUIPMENT WARRANTY