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 or any unmet deductible**

Suppliers Charge for upgraded equipment: ____________________________________- purchase/rental

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

I understand that________________________________ will bill Medicare for the ______________________ (purchase/rental) on a non-assigned basis. I will pay the suppliers charge for the cost of the upgraded __________________________________ and Medicare will reimburse me 80% of the allowed amount of the item that I would qualify for under Medicare guidelines. (see explanation below). I also understand that if I am dissatisfied with the upgraded DME that I have the right to return the item within 30 days**(proposed) (*** 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).