carePAC – DME Receipt Form

Patient Last Name

Patient Firs Name

Patient Middle Name (MI)

Patient DOB

Patient Sex
—Please choose an option—MFO

Patient ID#

Hospital/Clinic

Hospital/Clinic Address

Provider

Date of Service

NPI#

Comments

Contact E-Mail

Certification

This is to certify that on the client received the
carePAC (equipment) as prescribed by the physician. The equipment has been properly fitted to the client
and/or meets the client’s needs.

The client, parent, the guardian of the client, and/or caregiver of the client has received training and instruction
regarding the equipment’s proper use and maintenance.