Patient Notice: Durable Medical Equipment Waiver

Dear Patient:

For your convenience, Modern Foot and Ankle has entered into an arrangement with Med Resources, Inc. (“Med Resources”) to provide certain durable medical equipment and related supplies (“Items”). Med Resources has provided Modern Foot and Ankle with a closet of inventory from which we can provide you certain Items when you are discharged from the Facility.

Your physician has issued an order for the following Items (include type of item, brand, and quantity):

You have the right to receive these Items from any DME supplier, though not all health insurance plans contract with all suppliers. You have elected to receive the Items listed above from Med Resources. Please be advised that Modern Foot and Ankle has a contractual arrangement with Med Resources, but neither Med Resources nor Modern Foot and Ankle receive any compensation through the arrangement. If you do not wish to use Med Resources as your supplier of the Items listed above, please let Modern Foot and Ankle staff know, and staff will provide you with a listing of other suppliers that could also provide you with these Items.

By signing this notice, below, you are indicating that you understand the relationship between Modern Foot and Ankle and Med Resources, you have had the opportunity to select a supplier, and you have chosen Med Resources as your supplier.

If you have any questions, please let us know and we will be happy to discuss them with you.

Sincerely,

Modern Foot and Ankle