Attachment E - 2.docx

Attachment E VA-VISN 12 VETERAN RIGHTS AND RESPONSIBILITIES (R&R) (2 of 2)

Patient Name: _____________________________________Last 4 SN__________DOB:___________

PROVISION OF PRODUCTS:

I understand that my signature on this agreement authorizes Company to provide the products and/or services to me. I also understand that the products and/or services provided to me by Company or its agents are provided under the direction of my physician and that Company is not liable for any act or omission when following the instructions of my physician. I will grant visits to my residence for the home oxygen supplier to perform tasks directed by the VA for oversight of my equipment, supplies and service.

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NOTE!! OXYGEN CLIENTS:

I have received written and verbal instruction on the safe use, storage, and handling related to oxygen therapy. I understand that smoking or open flames are not allowed within 10 feet of the oxygen equipment or my person while oxygen therapy is used, as oxygen supports combustion. Any use of either is at my own risk and considered a safety hazard which may cause injury and even death.

ELECTRICAL SAFETY:

If I have been informed that my electrical outlets are not grounded, I have the option of having this condition corrected by a certified electrician or using the equipment "as is". If I choose to use the equipment with a non- grounded outlet, the Company is not responsible for any problems associated with such use.

By signing below, I certify that I have read the foregoing, received a copy thereof, and am the patient, or duly authorized by the patient as the patient's general agent to execute the above, and accept its terms on behalf of the patient.

Patient Signature:

Date:

Employee Signature: _______________________________________________________

Date: ___ VA 1624 Clinical Respiratory Assessment – Vent (VISN 12) Rev 6/4/2020