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