Acknowledgement of Understanding

I have been instructed and understand the safe use and maintenance of the following equipment/therapy. I have received the Patient Information Package, and I have been informed of:


Basic Home Safety

Notice of Privacy Practices

Emergency Preparedness

Customer’s Rights and Responsibilities

Terms of Agreement

Manufacture User Guide


I consent to have the Company release or obtain my medical records for the purpose of providing me with medical treatment. I understand that my records may also be used or disclosed in accordance with the HIPAA Standards for Privacy of Individually Identifiable Health Information (the Privacy Rule) as outlined in the Company’s Notice of Privacy Practices. I understand that my medical records will be destroyed only per state or federal regulations.


CONSENT FOR TREATMENT: I hereby consent to have the Company staff to ship and provide instructions for that which has been prescribed by my physician.