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Sample Medicare DME Proof of Delivery Form

Sample Proof of Delivery (POD) form for dental practices enrolled as a Medicare Supplier for sleep apnea oral appliances

MEDICARE DME PROOF OF DELIVERY


Patient’s Name: ________________________________

DOB: _________________________

Oral Appliance Description:

__________________________________________________________________

Delivery Address:

__________________________________________________________________

Quantity: 1

  • Beneficiary has been given instruction on the use of the Oral Appliance to treat Sleep Apnea
  • Beneficiary has been given instruction on the cleaning of the Oral Appliance
  • Beneficiary has been notified of the warranty coverage of the Oral Appliance
  • Beneficiary has been given a copy of the Medicare DMEPOS Supplier Standards

By signing this delivery ticket, I acknowledge that I have received the Oral Appliance listed above and the provider has given a demonstration on the proper use and cleaning of the product. I have also been given the warranty information and a copy of the Medicare DMEPOS Supplier Standards.

Patient Signature: ____________________________________

Date: ____________________