Rental Agreement: If this is a Delivery Ticket for Rental of equipment the following terms apply: The Customer acknowledges receipt of the equipment described, on the service dates indicated and agrees that title to the equipment shall at all times be and remain in Health Aid Company, Inc. (“Company”); that this is a transaction of lease only; that the equipment is accepted in its “as is” condition (having been inspected by the Customer upon delivery); and further, the Customer agrees: to protect the equipment from all loss, damage and misuse and remain responsible for it, to release the equipment for pick-up only to a duly authorized representative of Company, to operate the equipment only in the manner for which it was intended, to refrain from making any repairs to the equipment but notifying Company in the event repairs are necessary, to promptly and faithfully pay the stated rental each month or week (with-out pro-rate) until the equipment has been returned. The Customer has been informed and agrees that Company is not the manufacturer of the equipment, and is not responsible for the adequacy of the same nor any defects in the equipment or which may appear from the use and maintenance thereof, nor shall Company be responsible for any delay or interruption in connection with the delivery or service of the equipment whatsoever relating to the use of the equipment. Company has not prescribed the equipment, and makes no representations with regard to the suitability of the equipment for any specific purpose of the Customer, and assumes no liability for any warranties whatsoever, express or implied. The Customer agrees to accept whatever warranties are offered by the manufacturer of the equipment in lieu of any warranties of seller. The Customer irrevocably agrees to indemnify and save Company harmless from and against any claims whatsoever which may be brought by any persons whomsoever arising from the rental, delivery and use of the said equipment.

Sales Agreement: If this is a Delivery Ticket for Sale of equipment the following terms apply: The Customer acknowledges receipt of the equipment described, on the date indicated, and agrees that the equipment is accepted in its “as is” condition (having been inspected by the Customer upon delivery). The Customer agrees to pay the stated price for the equipment. The Company (“Seller”) has not prescribed the equipment, and further makes no warranty whatsoever express or implied of merchantability or fitness for purpose. On the contrary, the Customer has been informed and agrees that he or she knows that Seller is not the manufacturer of equipment and is not responsible for the adequacy of the same, nor for any defects in the equipment. The Customer irrevocably agrees to indemnify and save Seller harmless from and against any claim whatsoever which may be brought by any persons whomsoever arising from the sale, delivery and use of the said equipment.

Pick-Up Agreement: The Customer agrees to the following terms and conditions upon return or pick-up of equipment. All equipment is subject to inspection before it is picked up or returned. If any damage, unnecessary abuse, missing or broken items are reported, Customer will be notified and charged a fine. Service will be terminated and equipment shall be returned to Company if Customer has an overdue balance.

Insurance: When Company agrees to accept assignment and bill Customer’s insurance carrier on Customer’s behalf, Customer understands that Customer is responsible for any and all charges not subsequently received by Company. Customer also acknowledges that Customer is responsible for paying applicable deductibles and percentages not covered under Customer’s insurance program. Customer understands that most insurance plans including Medicare will not cover equipment in a nursing home or while in the hospital.

Default: In the event the Customer refuses to make any payment required by this agreement within ten (10) days after such payment becomes due, the Customer will be in default for purposes of determining the accruement of any remedies to which Company may be entitled under this agreement or the laws of the state of Florida. In addition to all other sums, the Customer may be obligated to pay a reasonable sum for attorney fees and court costs. Upon default, Company shall be entitled to immediate possession of property in Customer’s possession. Company requires a credit card imprint as a deposit on all rental items. If Customer’s account becomes seriously delinquent, and no effort is made on Customer’s part to bring the account up to date, Company reserves the right to charge Customer’s credit card for the past due balance.

Sales Returns: Sales returns may be accepted in unopened packages and salable condition within thirty (30) days from the date of original invoice with proof of purchase. No merchandise may be accepted for return if worn next to the skin or used for sanitary or hygienic purposes, such as items used in the bathroom. Special order merchandise is non-returnable.

Complaints: Those wishing to express a complaint or concern are encouraged to do so during regular business hours by either calling 813-879-7552 or filling out our Customer complaint form and returning this form to our office. Your comments will be reviewed and acted upon within five (5) days, or as soon as reasonably possible.

Entire Agreement; Non Waiver; Severability: This agreement contains the entire agreement and understanding between dealer and Customer relating to the subject matter herein. No agreements shall be binding on the parties hereto unless set forth in writing and signed by both parties. Time is of the essence in this agreement. No waiver by the Company or any breach or default shall constitute a waiver of any additional or subsequent breach or default of Customer nor shall it be a waver of any of Company’s rights. Any provisions of this agreement that for any reason may be held to be unenforceable shall not invalidate the remaining provisions of this agreement.

Rental and Retail Prices: Subject to change without notice.

Hours of Operation: 9:00 AM to 5:00 PM, Monday through Friday and 9:00 AM to 12:00 PM on Saturday, subject to change without notice. Questions regarding equipment can be addressed during normal business hours. Questions regarding insurance issues are limited to normal business hours, Monday through Friday.

Confirmation of Warranty Information: Customer has received a copy of the warranty information offered by the manufacturer, when applicable. Customer will contact the manufacturer as requested under the warranty information.

Privacy Policy: Customer certifies by signing the front of this form that Customer has received a copy of Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of Customer’s protected health information that might occur in Customer’s treatment, payment of Customer’s bills or in the performance of our Company’s health care operations. The Notice of privacy Practices also describes your rights and our Company’s duties with respect to your protected health information.

Bill of Rights/Medicare Supplier Standards: If this claim is being billed to Customer’s insurance, Customer certifies that Customer has received a copy of the Bill of Rights and Responsibilities and the Medicare Supplier Standards, if applicable.

Assignment of Benefits: The Customer agrees to assign to the Company any and all insurance benefits otherwise payable to Customer for service rendered, supplies and/or equipment; to immediately forward any benefits or checks otherwise sent directly to Company to Company’s address on face side; To be responsible for all insurance Co-Payment amounts within thirty days of receipt of the balance due. Company reserves the right to accept assignment on an individual or case by case basis. Should it become necessary to turn Customer’s account over to a collection agency, Customer assumes full responsibility for all legal expenses incurred.

Customer Agreement: A copy of the above terms and conditions are on file. Customer signature, or the signature of any party taking responsibility for delivery of equipment on behalf of the Customer indicates full understanding, compliance, and responsibility with this entire agreement; this includes granting permission to Company to use a copy of the entire agreement in place of the original.

Rent/Purchase Option: CMS policy states beneficiaries (Customers) may either rent or purchase inexpensive routinely purchased durable medical equipment. Should the Customer wish to discuss this, Customer should contact our office.

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