PATIENT: ACCOUNT #:

EQUIPMENT:
CPAP Machine E0601
Bi-PAP Machine E0470
Bi-PAP Machine ASV E0471

REASON FOR RETURN:

Patient did not use the machine.
Insurance would not cover/reauthorize the machine.
The patient did not want to purchase the machine for continued therapy. Equipment must be returned
as all options have been exhausted.

IMPORTANT: My physician has ordered the above stated equipment for my use, as necessary for the
treatment of my medical condition. However, I have decided not to proceed with continued therapy as
ordered by my physician for one or many of the Reason(s) for return aforementioned.

I am aware that I am making this decision against medical advice and that I am solely responsible for this
decision. I understand the consequences of my decision as they have been fully explained to me. I am fully
responsible for the consequences of this decision and release Landauer Medstar and related companies
from all liability associated with this decision.

SIGNATURE OF PATIENT: DATE:

(or responsible party)

PRINTED NAME:
(if responsible for party - please specify relationship to patient)

QMES REPRESENTATIVE SIGNATURE: DATE:

PRINTED NAME: