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DeliveryPickupRented
Date:

Patient Name:

Account Number:

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Your Email

DOB:

Model:

Height:

Weight:

Serial #:

Type:

Description:

Comments/Instructions:

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. I authorize payment of medical benefit to the undersigned supplier of services described. In the event of any loss or damage to the above-mentioned Choose One , the Medical Equipment will become the financial responsibility of the undersigned. The undersigned has been properly instructed about the safe operating procedures for this Medical Equipment. The undersigned further agrees not to alter the equipment in any way, agrees that the Choose One is for in home use only and agrees to hold harmless American Medical Equipment Supplies and Repairs, LLC, and its representatives, for any injuries or damages that may result from use of this Choose One .

Signature of Giver

Signature of Receiver

Delivered By:

Received By:

Scheduled Date:

Date Delivered or Picked Up: