INVOICE FOR SERVICES RENDERED

INVOICE FOR SERVICES RENDERED

Record details of services rendered and equipment dispensed.
SMG MEDIQUIP, LLC

P.O. BOX 736, BETHPAGE, NY 11714

PHONE: 516-586-4934 / FAX: 800-717-2573
Doctor*
Patient Name*
Upon our receipt of this invoice, SMG Mediquip will issue you a fee for evaluation and training as indicated below.
TENS/EMS UnitLumbar Brace (LSO)Lumbar Brace w/ Pneumatic TractionPostural/Thoracic TLSOCervical Traction UnitKnee Brace
Administrative — Completed, reviewed and ensured the detail and accuracy of the recommendation for durable medical equipment. Conveyed to patient their rights and obligations. Served as a point of distribution for the product.Instructional Usage — Instructed the patient on the proper use and functioning of the equipment (For TENS/EMS units: care of the electrodes, electrode placement, and settings). Reviewed all warnings and contraindications of the unit with patient.Monitoring — Made all initial parameter settings. Will assess patient progress and compliance through initial 30-day trial period.
The equipment prescribed to this patient was based solely on medical necessity. Compensation for fittings is standardized and based on mutually agreed upon remuneration, reviewable on a 12 month rolling basis, consistent with fair market value and not connected in any manner with referral volume. Furthermore, I agree to provide reasonable suppotting documentation (i.e. progress reports, medical records, etc.) in order to verify medicaj necessity.
I certify, that the services indicated above have been performed.
Signature*

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