Product Purchase/Supply Agreement

The product purchased/supplied which was determined to be defect-free and safe to use was supplied by DME Living Well. I have been informed that I may obtain this equipment from any supplier of my choice and I chose to receive it from DME Living Well. 

I acknowledge I received the product along with warranty information and instructions for use, And I understand how to properly use the device. I acknowledge I have not received the same or similar product for the same body part and diagnosis within the past year. 

I acknowledge that the medical product that is supplied cannot be returned. Replacement may be allowed for defective products per manufacturer warranty. Custom fabricated products are non-returnable per manufacturer.

I acknowledge I have received and understand the attached HIPAA Privacy Practice Notice and CMS supplier standard statement. I can retrieve a copy of these documents as well as DME Living Well's Patient Rights & responsibilities on this website. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call 860-674-1601 and speak to a manager. 

I authorize the release of any medical information necessary to file this claim. I assign and transfer to the above supplier any and all rights to receive payment of benefits for products or services provided by the supplier. I authorize my insurance carrier to furnish any and all information pertaining to my insurance benefits and status of claims submitted by this supplier. I understand and agree that I am responsible for any deductibles or coinsurances associated with my insurance benefit. I understand that I am responsible to pay DME Living Well for items not covered by my insurance plan.