INVOICE FOR SERVICES RENDERED

SERVICES:*

ADMINISTRATIVE: Completed, reviewed and ensured the detail and accuracy of the recommendation for durable medical equipment. Conveyed to patient their rights and obligations. Served as a point of distribution for the product.INSTRUCTIONAL USAGE: Instructed the patient on the proper use and functioning of the equipment (For TENS/EMS units...care of the electrodes, electrode placement, and settings). Reviewed all warnings and contraindications of the unit with patient.MONITORING: Made all initial parameter settings. Will assess patient progress and compliance through initial 30-day trial period, and make all appropriate adjustments based on the patient's unique treatment plan.

The equipment prescribed to this patient was based solely on medical necessity. Compensation for fittings is standardized and based on mutually agreed upon remuneration, reviewable on a 12 month rolling basis, consistent with fair market value and not connected in any manner with referral volume. Furthermore, I agree to provide reasonable supporting documentation (i.e. progress reports, medical records, etc.) in order to verify medical necessity.

I certify, by checking the boxes above, that I have performed the services indicated.

Signature*

Date:*

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INVOICE FOR
SERVICES RENDERED

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