Equipment Discharge Acknowledgement

Equipment Discharge Acknowledgement
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Authorized Representative

First NameLast Name
If I am signing as the patient’s authorized representative, I certify that I have the legal authority to act for the patient as indicated above and, by initialing here, I confirm I have read, understand, and agree to the statements in this section and the referenced documents.
I, {authorizedRepresentative} {patient/representative}, acknowledge and understand the following:

1. The oxygen equipment I am receiving is provided by High Country Oxygen (HCO2) on a rental basis and remains the property of High Country Oxygen.

2. I have reviewed and understand the instructions for safe use and handling of the equipment, including oxygen safety precautions.

3. All billing for the oxygen equipment and related services is between High Country Oxygen and myself ({authorizedRepresentative}). The hospital, clinic, or discharging facility is not responsible for billing or collection of this equipment.

4. I am responsible for arranging the return of the oxygen to HCO2 when no longer needed, or if requested by High Country Oxygen.

5. Travelling with oxygen will be at my expense and arrangements must be made prior to my departure from HCO2's Service Area, or additional fees may be incurred.

6. I understand that additional required paperwork will follow this submission and must be completed to finalize my rental and ongoing use. I can be reached at the following phone number and email address:
Phone Number

Country CodeArea CodePhone Number
Email
example@example.com
By providing your phone number, you agree that High Country Oxygen may contact you by text message about your equipment rental — including delivery and pickup coordination, service and supply questions, and follow-up on required paperwork. Message and data rates may apply. Message frequency varies. Reply HELP for help or STOP to opt out.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Serial number found on equipment tag
Hidden Number
Signature
Should be Empty: