Medicare Capped Rental and Inexpensive or Routinely Purchased Items Notification for
Services on or after January 1, 2006
I received instructions and understand that Medicare defines the equipment/ products that I received as being either a capped rental or an inexpensive or
routinely purchased item.
FOR CAPPED RENTAL ITEMS:
- Medicare will pay a monthly rental fee for a period not to exceed 13 months, after which ownership of the equipment is transferred to the Medicare
beneficiary.
- After ownership of the equipment is transferred to the Medicare beneficiary, it is the beneficiary’s responsibility to arrange for any required equipment
service or repair.
- Examples of this type of equipment include:
Hospital beds, wheelchairs, alternating pressure pads, air-fluidized beds, nebulizers, suction pumps, continuous airway pressure (CPAP) devices,
patient lifts, and trapeze bars.
FOR INEXPENSIVE OR ROUTINELY PURCHASED ITEMS:
- Equipment in this category can be purchased or rented; however, the total amount paid for monthly rentals cannot exceed the fee schedule purchase
amount.
- Examples of this type of equipment include:
Canes, walkers, crutches, commode chairs, low pressure and positioning equalization
Medical Record Release Authorization
By initialing and signing below, I hereby authorize the release of my medical records from the office/facility of my prescribing physician to HEALTHCARE
DME, LLC for the purposes of substantiating medical necessity for the item(s) which I have received from HEALTHCARE DME, LLC.
I hereby release the following types of medical records: Office/Progress Notes, Lab Reports, PT/OT Therapy Notes, and Nursing Records related to the
diagnosis(es) and/or medical condition(s) for which I was prescribed the item(s) provided by HEALTHCARE DME, LLC.
Also, by initialing and signing below, I attest that I understand that I may submit a written revocation of this release to HEALTHCARE DME, LLC at any time,
thereby terminating this authorization. Otherwise, this release shall remain effective for a period of time no longer than 5 years from the date listed below.
I understand that I may request a copy of this release.
By initialling each section as listed below, and with my signature, I hereby attest that I understand, acknowledge, agree to, and authorize the above-listed
sections. I understand that my signature only acknowledges, confirms agreement, and authorizes those sections as listed below for which I have
indicated acknowledgement, agreement, and authorization with my initials.
I also understand that it is my right to refuse to acknowledge, agree to, and authorize any section, indicated by a lack of initials