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PROOF OF DELIVERY OF ORAL DEVICE

Description: E0486, CUSTOM ORAL DEVICE

Quantity: 1

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. 

First Patient's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
First Patient's Date of Birth*
Date of Birth
First Patient's WHO ARE MEDICARE MEMBERS
Please check all that apply:
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
First Patient's Signature*
Second Patient's Name
First Name*
Middle Name
Last Name*
Select Gender
Patient's Date of Birth*
Date of Birth
Second Patient's WHO ARE MEDICARE MEMBERS
Please check all that apply:
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
Third Patient's Name
First Name*
Middle Name
Last Name*
Select Gender
Patient's Date of Birth*
Date of Birth
Third Patient's WHO ARE MEDICARE MEMBERS
Please check all that apply:
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
Fourth Patient's Name
First Name*
Middle Name
Last Name*
Select Gender
Patient's Date of Birth*
Date of Birth
Fourth Patient's WHO ARE MEDICARE MEMBERS
Please check all that apply:
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
Fifth Patient's Name
First Name*
Middle Name
Last Name*
Select Gender
Patient's Date of Birth*
Date of Birth
Fifth Patient's WHO ARE MEDICARE MEMBERS
Please check all that apply:
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
Sixth Patient's Name
First Name*
Middle Name
Last Name*
Select Gender
Patient's Date of Birth*
Date of Birth
Sixth Patient's WHO ARE MEDICARE MEMBERS
Please check all that apply:
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
Seventh Patient's Name
First Name*
Middle Name
Last Name*
Select Gender
Patient's Date of Birth*
Date of Birth
Seventh Patient's WHO ARE MEDICARE MEMBERS
Please check all that apply:
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
Eighth Patient's Name
First Name*
Middle Name
Last Name*
Select Gender
Patient's Date of Birth*
Date of Birth
Eighth Patient's WHO ARE MEDICARE MEMBERS
Please check all that apply:
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
Ninth Patient's Name
First Name*
Middle Name
Last Name*
Select Gender
Patient's Date of Birth*
Date of Birth
Ninth Patient's WHO ARE MEDICARE MEMBERS
Please check all that apply:
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
Tenth Patient's Name
First Name*
Middle Name
Last Name*
Select Gender
Patient's Date of Birth*
Date of Birth
Tenth Patient's WHO ARE MEDICARE MEMBERS
Please check all that apply:
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
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
The products and/or services provided to you by supplier Ramsey Dental are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained from the U.S. Government Printing Office website. Upon request we will furnish you a written copy of the standards.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's WHO ARE MEDICARE MEMBERS
Please check all that apply:
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
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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