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Sample Warranty Form for Medicare DME Suppliers

Sample warranty information form for dental practices enrolled as a Medicare DME Supplier for sleep apnea oral appliances.

DME Supplier, Inc.

17 Main Street

Anywhere, SC 29999

 

EQUIPMENT WARRANTY INFORMATION FORM

Every product sold or rented by our company carries a 1-year manufacturer’s warranty.

__________________ (Name of the company) will notify all Medicare beneficiaries of

the warranty coverage and we will honor all warranties under applicable law.

__________________ (Name of the company) will repair or replace, free of charge,

Medicare-covered equipment that is under warranty. In addition, an owner’s manual with

warranty information will be provided to beneficiaries for all durable medical equipment

where this manual is available.

I have been instructed and understand the warranty coverage on the product I have

received.

                               

Beneficiary's Name (printed) ____________________________________

Beneficiary’s Signature ________________________________________


Date_______________________