Name, Make, Model & MSRP of item delivered:_____________________________________________

Suppliers Charge for non-upgraded equipment: _________________________________ purchase/rental

Beneficiary out of pocket cost for non-upgraded equip.:**__________________________purchase/rental
** Includes 20% co-pay and any unmet deductibles**

Suppliers Charge for upgraded equipment: _________________________________- purchase/rental

Beneficiary Out of pocket for upgraded equipment:** ___________________________- purchase/rental
** Includes 20% co-pay and any unmet deductibles**

I understand that **__________________ will bill Medicare for the _______________ as a (purchase/rental) & I will be billed for the difference between the supplier’s charge for the upgraded ________(DME item) and the suppliers charge for the non-upgraded ________(DME item) as well as the 20% co-pay for the non-upgraded item and any unmet deductibles.  I also understand that if I am dissatisfied with the upgraded _________________(DME item) that I have the right to return the item within 30 days**(proposed) and receive a full refund for the upgraded portion of the _________________(DME item) from **___________________ & **__________________________ would be required to furnish a non-upgraded item to me. (***Medicare will allow ** ______________________ for the non-upgraded equipment less any applicable part B deductible and coinsurance***)

***Durable Medical Equipment (DME) is equipment furnished by a supplier or a home health agency that is primarily and customarily used to serve a medical purpose. While Medicare will pay for DME that is adequate and effective to meet the medical necessity needs of the beneficiary, it will not pay extra for convenience or luxury features nor more than the applicable fee schedule amount. Coverage is for Medical Necessity for use “in the home” and not specifically for use outside the home or for convenience of transporting the item.

**__________________________ has fully explained to (beneficiary or beneficiary representative) the above rule concerning payment for the _________________________________ that was chosen by _________________________________ for _________________________________. A full disclosure of my rights and responsibilities as well as the responsibility of **____________________________ was given to me by __________________________________ ( person explaining to patient or representative).

Signature of Patient/ Representative ________________________________________ Date: _________

**If Representative** WHY can patient not sign. _____________________________________________

Signature of Supplier: ____________________________________________________ Date: _________

This form is for your use to educate the beneficiary/representative is does not replace the optional ABN form (HCFA-R-131).