Summit Oxygen (+Tax) Electronic Forms
  • Summit Oxygen Inc.

    117 S 6th Ave Suite A-1 Frisco, CO 80443 P.O. Box 722 Frisco, CO 80443 PHONE: 970-468-0142
  • Personal Information

  • SUMMIT OXYGEN DOES NOT IMPLY, STATE OR MAKE ANY REPRESENTATION OF MEDICAL BENEFITS. EMPLOYEES OF SUMMIT OXYGEN ARE NOT MEDICAL DOCTORS, IF SICK YOU SHOULD CONSULT A PHYSICIAN.

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  • Product and Credit Card Authorization Form

    By completing this form, you authorize Summit Oxygen, Inc. to charge the agreed-upon amount to the credit card provided. You agree to pay for this purchase or rental of services, in accordance with your cardholder agreement with the issuing bank. If rented equipment is not returned in the same condition in which it was received, you authorize Summit Oxygen, Inc. to charge applicable repair, replacement, or equipment costs using the deposit or credit card on file.
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    Oxygen Concentrator Rental Product Image
    Oxygen Concentrator Rental

    Rental

    $130.00
      
    Additional Nights (After 1st Day Rental) Product Image
    Additional Nights (After 1st Day Rental)
    $55.00
      
    Oxygen Cannula Product Image
    Oxygen Cannula

    Accessories 

    $6.00
      
    CPAP Bleed-in Adapter Product Image
    CPAP Bleed-in Adapter

    Accessories 

    $10.00

    Item subtotal:$0.00
      
    CPAP Masks Product Image
    CPAP Masks

    Accessories 

    $95.00
      
    7" Tubing Product Image
    7" Tubing

    Accessories 

    $6.00
      
    25" Tubing Product Image
    25" Tubing

    Accessories 

    $8.00
      
    50" Tubing Product Image
    50" Tubing

    Accessories 

    $16.00
      
    Humidity Jar Complete Set Up Product Image
    Humidity Jar Complete Set Up

    Accessories 

    $22.00
      
    O2 Water Trap Only Product Image
    O2 Water Trap Only

    Accessories 

    $8.00
      
    Oxy Mask Product Image
    Oxy Mask

    Accessories

    $15.00
      
    Y Splitter Product Image
    Y Splitter

    Y splitter allows one oxygen source to be divided into two outlets, making it possible to connect two nasal cannulas to a single oxygen concentrator

    $10.00
      
    Pulse Oximeter Product Image
    Pulse Oximeter

    Accessories 

    $35.00
      
    7" Canula Multi Pack Product Image
    7" Canula Multi Pack

    $5 Each when you buy 10 or more. Limit 20 per order.

    $50.00
      
    Oxygen Bar Product Image
    Oxygen Bar

    Special Events (Weddings, Conferences, Reunions, etc). Ask for pricing.

    $ Free
      
    Oxygen Cylinder Refills Product Image
    Oxygen Cylinder Refills

    Any Size Tank (Must Be Exchange Only)

    $32.00
      
    Oxygen Cylinder Purchase (Size E Full Tank) Product Image
    Oxygen Cylinder Purchase (Size E Full Tank)
    $180.00
      
    Oxygen Cylinder Purchase (Size B and D Full Tank) Product Image
    Oxygen Cylinder Purchase (Size B and D Full Tank)
    $130.00
      
    Adult Oxygen Regulator Product Image
    Adult Oxygen Regulator

    Purchase

    $55.00
      
    O2 Conserving Regulator Product Image
    O2 Conserving Regulator

    Purchase

    $225.00
      
    O2 Conserving Regulator Product Image
    O2 Conserving Regulator

    Rental

    $25.00
      
    Osprey Talon Oxygen Pack Product Image
    Osprey Talon Oxygen Pack

    Purchase

    $200.00
      
    Adult OR Pediatric Regulator Product Image
    Adult OR Pediatric Regulator

    Rental

    $20.00
      
    Delivery Fees (Location Specific) Product Image
    Delivery Fees (Location Specific)

    Delivery Fees

    $95.00
      
    Oxy Go Next Portable Oxygen Concentrator Product Image
    Oxy Go Next Portable Oxygen Concentrator

    Purchase

    $2,799.00
      
    Oxy Go Fit Portable Oxygen Concentrator Product Image
    Oxy Go Fit Portable Oxygen Concentrator

    Purchase

    $2,799.00
      
    Portable Oxygen Concentrator Rental Product Image
    Portable Oxygen Concentrator Rental

    Rental

    $150.00
      
    Portable Oxygen Concentrator Rental Additional Nights Product Image
    Portable Oxygen Concentrator Rental Additional Nights

    Rental

    $75.00
      
    Oxygen Cylinder (B & D) Tanks Rental Product Image
    Oxygen Cylinder (B & D) Tanks Rental
    $60.00
      
    coupon loading
    Subtotal
    $0.00
    Tax
    $0.00
    Total
    $0.00

    Credit Card
    Billing Address
  • Customer Rights and Responsibilities

  • Normal business hours are 9:00am - 5:00pm M-F an after-hours charge will be applied to all services outside these hours.

    It is understood by the parties to this agreement that the word "COMPANY" when used in this agreement, refers to Summit Oxygen. The "CUSTOMER" is understood to be the person receiving equipment and/or supplies from the Company. Individuals signing for the customer represent that they are duly authorized and that once signed, this agreement becomes binding, jointly and severally, upon the customer and the signor.

    The customer agrees to care for, use as instructed, and return the rental equipment in good condition, normal wear and tear excepted, at the end of the rental period. The customer agrees that services will renew automatically, and billing will continue monthly until the equipment is returned to the company. The customer agrees to pay for the replacement cost of any equipment damaged, destroyed, or lost due misuse, abuse, or neglect. The patient agrees to a cleaning fee of $75 if the rental equipment is returned in an unsatisfactory condition due to neglect, lack of care, or smoke contamination. The customer agrees not to modify the rental equipment without the prior written consent of the Company. The customer agrees that any authorized modifications shall belong to the title holder of the equipment.

    The customer agrees that title to the rental equipment and all parts shall remain with the Company always, unless equipment is purchased and paid for in full. The customer agrees not to assign POSSESSORY RIGHTS in the rental equipment or allow the use of the rental equipment by anyone other than the customer.

    It shall be the responsibility of the customer to promptly notify the Company of any rental equipment malfunctions or defects, and allow Company equipment service representatives to enter the customer's premises at all reasonable times to REPAIR, relocate, perform regularly scheduled services, or provide adequate substitute equipment. The Company GUARANTEES all equipment to be delivered operating within manufacturer's specifications and to be fully warranted to the manufacturer's current policy. The Company fully warrants used equipment purchased for a minimum of thirty (30) days from the date of purchase.

    In the event the CUSTOMER and/or SIGNOR fails to pay for the equipment during the rental period or return equipment before the expiration of the rental period, DEFAULT INTEREST at twenty (20) per cent per annum shall accrue from the date of default. If collection efforts become necessary, the Company shall be asking for treble damages associated with conversion and rights in stolen goods under C.R.S. section 18-4-401 et seq. The customer agrees the Company shall not insure or be responsible to the customer for any PERSONAL INJURY OR PROPERTY DAMAGE related to any equipment, including that caused by use or improper functioning of the equipment, the act or omission of any other third party, or by any criminal act or activity, war, riot, insurrection, fire or act of GOD.

    The customer agrees that if they fail to make PAYMENT on any rental purchase within sixty (60) days after it becomes due, the Company shall have the right to pick up all equipment. Sales RETURNS will be accepted in unopened packages and/or sellable condition within thirty (30) days from original invoice with proof of purchase. A minimum of one-month rental may be deducted (where applicable No merchandise will be accepted for return if worn next to the skin, used for sanitary or hygienic purposes, or if it is disposable (i.e., nasal cannula Special order items will require a fifty (50) percent deposit and are non-returnable. The Company maintains twenty-four (24) hour availability by telephone.

    Qualified staff is always available to assist with equipment malfunction, or other emergancies. Should a life-threatening situation arise, it is suggested the customer or caregiver dial "911" for professional emergency assistance.

    Customer's wishing to express their dissatisfaction, concern, or content with any Company service should contact the Company, on business days between 9am and 5pm MST at 970-468-0142. All disputes must be brought to the attention of the Company within 30 days of last billing date. Your comments will be fully reviewed and acted upon, as necessary, by the Company. Your comments may be given without fear of reprisal by the Company, or any of its employees.

    It is understood that all customer's personal information shall be kept strictly CONFIDENTIAL by the Company and are not released without written consent, unless authorized by law.

    The Company retains the RIGHT TO REFUSE DELIVERY of service to any customer, at any time. This policy is in the interest of health and safety to Company employees. The Company also retains the right to refuse to place equipment in an unsuitable home environment where the equipment cannot be used safely or properly.

    All costs of collections, including but not limited to, attorney's fees, costs of service and filing, and/or other court costs shall be paid by the non-prevailing party. All actions concerning enforcement of dispute of this Agreement shall be venued in Summit County, State of Colorado.

    SIGNATURE ACKNOWLEDGES AND ACCEPTS ALL STATEMENTS AND PROVISIONS AS STATED. SUMMIT OXYGEN DOES NOT IMPLY, STATE OR MAKE ANY REPRESENTATION OF MEDICAL BENEFITS. EMPLOYEES OF SUMMIT OXYGEN ARE NOT MEDICAL DOCTORS, IF SICK YOU SHOULD CONSULT A PHYSICIAN.

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  • Oxygen Therapy Equipment Review

  • Client Understanding & Responsibility

    By signing this form, the client acknowledges they have received instruction on safe use, handling, and operation of all equipment provided by Summit Oxygen. The client understands how to contact the company in case of emergency and agrees to follow all safety guidelines.

    Equipment Operation Review (Concentrator / Portable Oxygen System)

    The following topics were reviewed and demonstrated:

    On/Off switch and basic operation
    Alarm indicators and appropriate response
    Proper ventilation — do not block intake or exhaust
    Liter flow knob and correct flow setting
    Regulator & washer placement
    Tubing connection
    Cylinder usage time and how to read the gauge
    How to turn a cylinder on and off
     Client acknowledges understanding of the above safety precautions.

    Safety Precautions:
    While oxygen itself does not burn or explode, an oxygen-enriched environment can cause fires to burn hotter, faster, and more intensely.

    To reduce risk:

    NO open flames within 5 feet of oxygen equipment
    NO smoking near oxygen
    NO devices that create sparks (lighters, matches, grills, etc.) within 5 feet
    Keep equipment in a well-ventilated area, away from heat sources
    Store cylinders securely in an upright position
    Client acknowledges understanding of the above safety precautions.

    Home Evaluation/Assessment or Re-Assessment

    Home environmental assessment includes identification of safety or health hazards, presence of adequate living arrangements, potential safety and security hazards (i.e. throw rugs, furniture layout, bathroom safety, cluttered stairways, blocked exits, unsecured doors, lack of smoke detectors, and fire risks

    Emergency Preparedness

    Client knows where to go to avoid danger in case of emergency (forest fire, power failure Client has been instructed how to move the necessary equipment. Client understands that in an emergency they may miss a treatment or delivery and further understands that they should not wait until the last moment to call or to stock up in case of such emergency.

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  • NOTICE OF PRIVACY PRACTICES /ACKNOWLEDGEMENT

  • Maintaining privacy of your health information is very important to us.

    Complete notice of Privacy Practices is available upon request. The following is a summary of the content of the Notice of Privacy Practices. We encourage you to read the entire notice and ask any questions you may have regarding its content.
  • How We May Use and Disclose Health Information About You.

    This section describes the different ways we may use or disclose your health information without first obtaining specific authorization from you. These types of uses and disclosures are specifically permitted by law because it is assumed you would want us to use or disclose your information for these purposes, or because such use or disclosure is recognized as critical to the functioning of our health care system.
  • Your Rights Regarding Your Health Information

    This section describes the following right you have with respect to your health information and tells you how you may exercise these rights.
  • Right to inspect and copy
    Right to request amendment
    Right to request an accounting of disclosures
    Right to request restrictions of certain uses and disclosures
    Right to request alternative means of communication
    Right to receive a paper copy of our Notice of Privacy Practices

  • How to File Complaints Concerning Our Privacy Practices.

    This section tells you what you can do if you believe any of your rights have been violated. You will not be penalized for filing a complaint. We ask you to acknowledge your receipt of the Notice by signing below. The most current copy of our Notice of Privacy Practices will be posted in our office. If there are material changes to this Notice later, you will be provided a copy of the revised Notice and asked to sign another acknowledgement. I acknowledge that I received or was offered a copy of my provider's Notice of Privacy Practices.
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