36C24420Q0407-002.docx

DME CHECK LIST (Attachment #1) Equipment repaired/provided: __________________________ VETERAN’S NAME: ____________________________ Last 4 SS# _________________________ Date: ______________________________ PO#: _________________________

TO BE SIGNED BY VETERAN/CAREGIVER

1. Was equipment working properly at time work was completed?

2. Were instructions in the care and safe use of the equipment provided?

3. Was a receipt or delivery notice provided showing the name and telephone number of the Contractor in the event service or repairs are needed?

4. Were you trained in the safe use of the equipment?

5. Were electrical cords, plugs, etc. undamaged and a safe grounded electric outlet available? If not, was patient advised that it is his/her responsibility to ensure safe, grounded outlet is available?

6. HIPPA Privacy Policy provided and explained?

7. VA Patient Rights and Responsibilities were issued and explained?

8. After hours emergency contact instructions and telephone numbers provided?

9. Work order was signed, dated, and copy provided?

Level of patient/caregiver understanding: ___poor ___fair ___good ___refused training I acknowledge the above checked items have been explained, completed and/or provided to me.

Comments:

Patient/Caregiver Signature Patient/Caregiver (Print) Last 4 SS# Date Contractor Rep Signature Contractor Rep. (Print) Ph # Date