Healthcare Equipment Add-On

Healthcare Equipment Add-On

Patient Information

Date of Birth:    Gender:

Insurance Information

Equipment Add-On Details

Effective Add-On Date:

Terms and Conditions — Equipment Add-On

1. Scope: Provider will supply the equipment listed above as an add-on to the existing equipment agreement between Provider and Patient. This add-on is governed by the original equipment agreement except where modified herein. Patient acknowledges that acceptance of this add-on constitutes agreement to all terms set forth in this document.

2. Charges and Payment: Patient authorizes billing to the named insurance carrier or, if not covered, direct billing to Patient. Patient is responsible for co-payments, deductibles, and any charges not paid by insurance. Monthly rental charges commence on delivery and will recur until the rental term expires or the equipment is returned in accordance with return procedures. Failure to pay may result in collection action and equipment retrieval.

3. Ownership and Title: Equipment rented under this add-on remains the property of Provider unless Patient purchases the equipment pursuant to an election above. Title transfers only upon a documented purchase transaction and payment in full. Patient shall not alter, dispose of, or permit liens against Provider property.

4. Maintenance, Repairs, and Returns: Provider is responsible for scheduled maintenance and repairs due to normal wear. Patient shall notify Provider promptly of malfunction. Damage due to misuse, neglect, or unauthorized repair is Patient's responsibility; Patient shall bear cost of repair or replacement. Equipment must be returned in clean, working condition with all accessories upon expiration or termination.

5. Loss, Theft, or Damage: Patient must report loss or theft immediately. Patient may be responsible for the replacement value if the equipment is lost, stolen without a police report, or irreparably damaged due to negligence. Provider may require a replacement fee or charge the insured party as applicable.

6. Insurance Authorization and Assignment: Patient authorizes Provider to submit claims to Patient's insurer for covered services and equipment. Patient assigns to Provider the right to receive insurance payments for billed equipment to the extent permitted by law. Patient remains responsible for amounts not paid by insurance.

7. Indemnification and Limitation of Liability: To the fullest extent permitted by law, Patient releases and indemnifies Provider and its agents from claims arising from Patient's misuse of equipment, failure to follow instructions, or failure to obtain necessary medical direction. Provider's liability for any direct damages arising from Provider's negligence shall be limited to actual documented damages not to exceed the amount paid by Patient for the specific add-on equipment during the preceding three months.

8. Governing Law and Dispute Resolution: This add-on shall be governed by the laws of the state applicable to the underlying equipment agreement. Disputes shall be resolved in accordance with the dispute resolution provisions contained in the original equipment agreement; if none exist, disputes shall be submitted to binding arbitration in the county of Provider's principal place of business.

9. Right to Revoke or Amend: Patient may request revocation or amendment of this add-on in writing; Provider may require return of equipment and payment for any use through the revocation effective date. Revocation does not affect charges already incurred or obligations for loss or damage.

HIPAA / Privacy & Authorization

Patient acknowledges receipt of Provider's privacy practices and authorizes the release of medical and billing information necessary to process claims and provide equipment services. This authorization includes communication with insurers, medical professionals, and billing agents as necessary for claims adjudication.

This authorization expires on: . Patient may revoke this authorization in writing except to the extent Provider or third parties have already relied on it.

I acknowledge receipt of the Provider's privacy practices and authorize release of protected health information as described above.

Patient Certifications

By signing below, Patient certifies that the information provided on this Healthcare Equipment Add-On form is true and accurate to the best of Patient's knowledge, that Patient has read and understands the terms and conditions herein, and that Patient authorizes Provider to furnish and bill for the equipment specified.

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