* I understand I am responsible to Rent Oxygen for all charges. I understand that the balance must be paid in full for the greed upon rental period at the time of delivery. Irecognize that I am fully responsible for the full replacement cost not returned or not returned in the same condition in which I received the item/items. I recognize that Rent Oxygen will not bill insurance.
* Medicare patients: Medicare will pay for medical equipment and supplies only if a supplier has a Medicare supplier number. We do not have a Medicare supplier number.Medicare will not pay for any medical equipment and supplies we sell or rent to you.You will be personally and fully responsible for payment.
* If this rental was result of a medical order/prescription, I hereby authorize release to Rent Oxygen any and all of my medical records pertaining to my medical history,services rendered, or treatments received from my physician(s) or hospital. In order to
help client submit an insurance claims, I also hereby authorize Rent Oxygen to furnishto my insurance carrier(s), any medical history, services rendered if requested by carrier(s).
* Equipment has been demonstrated and I and/or caregiver has been given verbal instruction on use. If medical order, I understand my prescription. I have company’s contact details, 844-699-4366, 24 hour / 7 days a week. I understand to call for medical assistance and Rent Oxygen if any change in client status.
* Release of Liability. I acknowledge that if the purpose of the oxygen is to adjust to altitude, sport or for recreational purposes, that if any medical condition arises while using the equipment, I must seek immediate medical help. I acknowledge and assume all risks and dangers that may arise or result of the supplemental oxygen or rental items. Additionally, in consideration for allowing Rent Oxygen to rent equipment, I agree to hold harmless, release and indemnify Rent Oxygen and any associated persons, or the accommodations in which you are staying, due to using the oxygen and equipment.