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: ____________________