Apria Healthcare Private and Confidential

DocuSign Envelope ID: B9508B0B-25D3-41AD-A156-52296273FE88 APRIA HEALTHCARE LLC
2612 NE INDUSTRIAL DRIVE

**DUPLICATE** KANSAS CITY MO 64117
1
CEU008 NEED(999) 999-9999
1842 X3934477 SALYAK, VIKTOR (646) 887-4188
711A SEAGIRT AVENUE 7CM H2O
10/19/21 APT 7H
FAR ROCKAWAY
MOSHENYAT, REUV *JGO21 NY 11691 MOSHENYAT, REUVEN
(646) 887-4188 (718) 645-8901
JULIA
(718) 645-8901 M 70 255
Environment Suitable? Yes_ No_ N/A_
*-------- DELIVERY --------*

1 EA SALE M056654 CPAP KIT NASAL AIRFIT N20 S/ 374.00 .00 .00
PICK LOC.: E08 .0010 G04 .0010 H09 .0050
Primary Ins: FIDELIS CARE NY 100
MODEL#: 63535
MANUF: RESMED INC
1 EA COMP M056638 CPAP MASK FRAME AIRFIT N20 M .00 .00 .00
MODEL#: 63555
MANUF: RESMED INC
1 EA COMP M056647 CPAP CUSH AIRFIT N20 LG .00 .00 .00
PICK LOC.: D03 .0030 H09 .0030
MODEL#: 63552
MANUF: RESMED INC
1 EA COMP M056649 CPAP CUSH AIRFIT N20 SM .00 .00 .00
PICK LOC.: D03 .0010 H09 .0010 I04 .0020
MODEL#: 63550
MANUF: RESMED INC
1 EA COMP M056657 CPAP HEADGEAR AIRFIT N20 MED .00 .00 .00
CONTINUES ON NEXT PAGE .....
1842 - X3934477 - CEU008

Printed: 10/20/21 14:38:44 Tax ID: 33-0057155
2
CEU008 NEED(999) 999-9999
1842 X3934477 SALYAK, VIKTOR 646 887-4188
10/19/21 APT 7H
FAR ROCKAWAY
(646) 887-4188 (718) 645-8901
JULIA
(718) 645-8901 M 70 255
MODEL#: 63561
MANUF: RESMED INC
1 EA SALE M049998 CPAP UNIT AIRSENSE 10 AUTOSE 471.39 .00 .00
PICK LOC.: E11 .0020 E16 .0010 E18 .0010
DEVICE#: ____________
SERIAL#: ____________________
MODEL#: 37207
MANUF: RESMED INC
1 PK COMP M049470 NO REORDER CPAP FILTER DISP .00 .00 .00
MODEL#: 36850
MANUF: RESMED INC
1 EA COMP M049996 CPAP HUMIDIFIER CHAMBER HUMI .00 .00 .00
MODEL#: 37299
MANUF: RESMED INC
1 EA COMP M049999 CPAP CARD SD F/AIRSENSE 10 .00 .00 .00
MODEL#: 37329
MANUF: RESMED INC
1 EA COMP M890190 CPAP TUBING F/CPAP .00 .00 .00
MODEL#:
MANUF:
1 EA COMP M890401 CPAP HUMIDIFIER .00 .00 .00
1842 - X3934477 - CEU008

Printed: 10/20/21 14:38:44 Tax ID: 33-0057155
3
CEU008 NEED(999) 999-9999
1842 X3934477 SALYAK, VIKTOR 646 887-4188
10/19/21 APT 7H
FAR ROCKAWAY
(646) 887-4188 (718) 645-8901
JULIA
(718) 645-8901 M 70 255
MODEL#:
MANUF:
1 EA COMP M891636 TRAINING & INSTRUCT DVD FOR .00 .00 .00
MODEL#:
MANUF:
SUB-TOTAL .00 .00
Previous Outstanding Balance .00

Amount Due for this Order .00
Amount Collected .00
Total Due Today .00
_ Credit _ Check
For service or questions about your equipment call: 800-638-0942

For insurance related questions call: 888-492-7742
For statement questions call: 866-505-6365
1842 - X3934477 - CEU008

Printed: 10/20/21 14:38:44 Tax ID: 33-0057155
4
CEU008 NEED(999) 999-9999
1842 X3934477 SALYAK, VIKTOR 646 887-4188
10/19/21 APT 7H
FAR ROCKAWAY
(646) 887-4188 (718) 645-8901
JULIA
(718) 645-8901 M 70 255
FINANCIAL RESPONSIBILITY: I acknowledge that the coverage terms imposed by the

patient's Third Party Payor(including health plans and insurance companies)
and the Company's agreement with such Third Party Payor include many
conditions and requirements that must be satisfied in order for the patient's
Third Party Payor to pay for the Equipment (including all supplies and
services) provided to the patient under this Agreement. These conditions and
requirements may include prior authorization, obtaining test results,
certification and other documentation, providing evidence of the patient's
compliance with the therapy requirements and periodic recertifications
of all of the foregoing. While the Company may assist the Responsible Party
and attempt to keep the Responsible Party apprised of any of these conditions
and requirements that affect the patient's right to reimbursement, in some
cases the conditions and requirements of the patient's Third Party Payor
may change or be applied in ways that are different than the Company
anticipates. In those cases, the patient's Third Party Payor may refuse to
authorize or pay for further treatment and may classify the patient's therapy
as not medically necessary or otherwise not covered, with the result that the
Responsible Party will, to the extent permitted by law, become financially
responsible for ongoing rental or purchase charges and the cost of related
Equipment at the rates reflected in this and other documents accompanying
future deliveries or shipments of supplies. Compliance with coverage and
billing requirements is the Responsible Party's responsibility, and, to the
extent permitted by law, the Responsible Party bears the financial risk of
non-compliance or denial of coverage. My signature on this document will
signify my agreement, as more fully reflected in this Agreement, to retain the
Equipment and that the Responsible Party will be financially responsible for
the cost of the Equipment and related supplies in the event the patient's
Third Party Payor should deny authorization or payment for further coverage
for any reason, to the maximum extent permitted by law. The Responsible
Party's financial responsibility for the Equipment will continue until it is
returned to the Company and the Responsible Party's responsibility for
ordered supplies can be avoided only by their return to the Company in an
unopened and unused condition within ten days after the patient receives them.
1842 - X3934477 - CEU008

Printed: 10/20/21 14:38:44 Tax ID: 33-0057155
5
CEU008 NEED(999) 999-9999
1842 X3934477 SALYAK, VIKTOR 646 887-4188
10/19/21 APT 7H
FAR ROCKAWAY
(646) 887-4188 (718) 645-8901
JULIA
(718) 645-8901 M 70 255
PAP PATIENT COMPLIANCE VERIFICATION:

I acknowledge and agree that, in providing PAP products and services, the
Company may obtain the patient's PAP therapy compliance information ("PAP
Compliance") using software and hardware (the "PAP System") that will
communicate with the patient, Responsible Party and/or me.
Without limiting any other authorizations provided to the Company and its
representatives and agents, I hereby request the Company to communicate with
the patient, Responsible Party and/or me regarding PAP Compliance (including
communications that may contain patient protected health information and/or
other personal information) by email, text messaging and/or telephone
(including leaving detailed voicemail messages). I understand that
communications regarding PAP Compliance may be made via the PAP System and/or
may be automated.
My preferred (but not exclusive) method of communication from the Company

regarding PAP Compliance is/are the following (please check one option and
provide the applicable address/phone number):
_____ Email, provide address:
______________________________________________
_____ Text Messaging, provide cell phone number:
___________________________
_____ Telephone Call (Voice), provide phone number:
________________________
I acknowledge that communications by voicemail messages, text messaging and

email (particularly if unencrypted) are not secure and can be misdirected or
intercepted and read or heard by parties other than the intended recipient.
I understand and agree that I am responsible for any costs associated with
telephone calls (including voicemails), text messaging and/or emails sent to
and received by me from or on behalf of the Company regarding PAP Compliance.
If none of the above preferred communication methods is selected, I am

requesting that the Company make all communications regarding PAP Compliance
by Telephone Call (Voice) at the phone number the Company has on file or
otherwise obtains.
If a phone number or email address for a selected preferred communication

method is not provided or is invalid, I request that the Company use any
other phone number(s) and/or email address(es) associated with the patient's
account or otherwise provided, directly or indirectly, to the Company or its
1842 - X3934477 - CEU008

Printed: 10/20/21 14:38:44 Tax ID: 33-0057155
6
CEU008 NEED(999) 999-9999
1842 X3934477 SALYAK, VIKTOR 646 887-4188
10/19/21 APT 7H
FAR ROCKAWAY
(646) 887-4188 (718) 645-8901
JULIA
(718) 645-8901 M 70 255
representatives or agents.
I acknowledge and agree that the preferred communication method(s) selected

above can be changed by calling the Company at (800) 327-2801.
1842 - X3934477 - CEU008

Printed: 10/20/21 14:38:44 Tax ID: 33-0057155
7
CEU008 NEED(999) 999-9999
1842 X3934477 SALYAK, VIKTOR 646 887-4188
10/19/21 APT 7H
FAR ROCKAWAY
(646) 887-4188 (718) 645-8901
JULIA
(718) 645-8901 M 70 255
This Agreement may be provided and signed in hardcopy or electronic (including

email) form. As used in this document, the term Agreement means this document
(including the terms and conditions section appearing below the signature
lines in electronic versions or as three alternating pages on the back of
hardcopy versions) and any other documentation provided by the Company. Some
terms used in this Agreement are defined in the terms and conditions section
of this document. All references in electronic versions of this document to
the front of this form refer to the provisions of this document which precede
the terms and conditions section. This Agreement applies to (i) all Equipment
listed above, (ii) any other Equipment provided to the patient and (iii) any
other arrangements or interactions between the Responsible Party and the
Company (except to the extent superseded by a subsequent agreement). In the
event of a conflict between the provisions on the front of this form with
those on the back, the provisions on the front of this form shall prevail.
Note to Veterans Administration (VA) beneficiaries: To the extent the

particular products or services the patient is receiving are covered by the
VA, the term Responsible Party" as used in this Agreement means the VA, and
the patient will not be financially responsible for any such charges except to
the extent provided otherwise under applicable laws, regulations, rules and
agreements.
COMMUNICATIONS: I acknowledge that communications by voicemail messages,

text messaging and email (particularly if unencrypted) are not secure and can
be misdirected or intercepted and read or heard by parties other than the
intended recipient. I understand and agree that I am responsible for any
costs associated with telephone calls (including voicemails), text messaging
and/or emails sent to and received by me from or on behalf of the Company.
This Agreement also documents my consent to receive communications (including
communications that may contain my protected health information) from the
Company via email, text and/or voicemail.
I understand that I am responsible for the payments described in this

Agreement and any other amounts I may owe to the Company, and I have (i)
completed the card information requested below; or (ii) confirmed that the
card information the Company has on file for me as provided below is correct
and up-to-date (including making any appropriate corrections). If the card
information below is left blank or is incorrect or invalid, I authorize the
Company to charge any other credit or debit card I have already provided or
may subsequently provide to the Company for any payments I may owe to the
Company.
1842 - X3934477 - CEU008

Printed: 10/20/21 14:38:44 Tax ID: 33-0057155
8
CEU008 NEED(999) 999-9999
1842 X3934477 SALYAK, VIKTOR 646 887-4188
10/19/21 APT 7H
FAR ROCKAWAY
(646) 887-4188 (718) 645-8901
JULIA
(718) 645-8901 M 70 255
I authorize the Company to charge my credit or debit card for any and all
rental, purchase and other charges due and owing by me to the Company,
including all deductibles, co-payments, and missed delivery charges; charges
for any Equipment that is not returned to the Company as agreed; and any other
charges which I may owe to the Company, whether such charges are one-time or
recurring (as further disclosed below). If a credit or debit card I have
provided to the Company (including any card that may be provided below) does
not work or cannot be charged, I authorize the Company to charge any other
card it may have on file for me.
In particular, I authorize the Company to charge my card for the amounts

specified in this Agreement, including:
1. Any onetime fees disclosed at the beginning of this document, any other
potential charges provided for in this Agreement and any other onetime fees
which the Company discloses to me in a subsequent agreement with the Company,
2. The monthly rental or other recurring fees listed at the beginning of this
document (collectively, the Recurring Charges).
3. The patient's annual deductible and any cost share or copayments calculated
and provided to the Company and the patient or the Responsible Party by the
patient's Third Party Payor. The Company will charge this amount in accordance
with the terms of any coverage the patient may have, as communicated by the
patient's Third Party Payor.
4. Charges for Equipment not returned to the Company as agreed, which will be
calculated using any remaining Third Party Payor contract balance, or, if
there is no such balance, a purchase price reasonably determined by the
Company, but not to exceed the Company's national retail charge.
RECURRING CHARGES. I acknowledge and agree that I am responsible for the

payment of all Recurring Charges. I authorize the Company to charge my card
for all Recurring Charges, less any amounts covered by and received from the
patient's Third Party Payor, until the applicable Equipment is paid for,
converted to sale or returned to the Company as provided in this Agreement. I
understand that I may cancel this authorization by writing to or calling the
Company at the address or billing/collections phone number provided on the
patient's billing statement. Any such cancellation shall be effective on
receipt by the Company and will cancel all Recurring Charges scheduled in the
future. If I cancel my authorization, I understand that I will be responsible
for making arrangements to pay all remaining recurring amounts owed to the
Company. If I cancel my authorization and fail to make subsequent payments,
I will immediately (within 10 days) return the Equipment to the Company in the
CONTINUES ON NEXT PAGE ..... Self
VIKTOR SALYAK
1842 - X3934477 - CEU008

Printed: 10/20/21 14:38:44 Tax ID: 33-0057155
9
CEU008 NEED(999) 999-9999
1842 X3934477 SALYAK, VIKTOR 646 887-4188
10/19/21 APT 7H
FAR ROCKAWAY
(646) 887-4188 (718) 645-8901
JULIA
(718) 645-8901 M 70 255
condition specified in this Agreement, unless the Company determines the

Equipment cannot be returned without unreasonably endangering the patient; in
which case, the Company may exercise its rights described in Section 6 in the
Acknowledgement and Agreement section below.
REINSTATING PRIOR RECURRING CHARGES: If I have previously canceled my

authorization to charge any credit or debit card for any monthly rental or
other recurring fees listed on any document signed by me or on my behalf
for any products provided to me by the Company that I have not yet returned
to the Company, I hereby revoke that cancellation and agree that all such
products are included in the definition of "Equipment" under this Agreement
and that all such charges are included in the definition of "Recurring
Charges" under this Agreement. Accordingly, I authorize the Company to charge
any credit or debit card that the Company may now or hereafter have on file
for me for those Recurring Charges until such Equipment is returned to the
Company as provided in this Agreement.
I understand that the Recurring Charges I am authorizing under this Agreement

are subject to change for a number of reasons, such as price adjustments by
the patient's Third Party Payor, the patient's enrollment with another Third
Party Payor or the patient's loss of insurance coverage. I further understand
that such adjustments may result in an increase in the Recurring Charges for
Equipment provided by the Company. In such event, I authorize the Company to
charge my card for any such changed Recurring Charges (less any amounts
covered by and received from the patient's Third Party Payor). I acknowledge
and agree that the Company will give me at least ten (10) days notice before
charging my card only if such changed Recurring Charges will be more than
fifty percent (50%) greater than the Recurring Charges authorized under this
Agreement.
By signing this document, I acknowledge and agree, to the extent permitted by

law, as follows:
1. I am the patient or the patient's parent, spouse, guardian or authorized
representative.
2. I agree to the terms and conditions contained in this Agreement.
3. This Agreement supersedes any prior agreements which may have been entered
into between the parties regarding any Equipment, except for payment terms,
delivery times, rental periods and other economic provisions specific to such
prior agreements, arrangements or transactions.
4. Unless this document is signed prior to the patient's receipt of the
Equipment, I acknowledge that:(i) the Responsible Party has received and
1842 - X3934477 - CEU008

Printed: 10/20/21 14:38:44 Tax ID: 33-0057155
10
CEU008 NEED(999) 999-9999
1842 X3934477 SALYAK, VIKTOR 646 887-4188
10/19/21 APT 7H
FAR ROCKAWAY
(646) 887-4188 (718) 645-8901
JULIA
(718) 645-8901 M 70 255
fully inspected the Equipment and it is complete and in good working order
without defects; and (ii)the Responsible Party has been instructed on the
proper care, use, service, safe operation, and maintenance of the Equipment as
appropriate and to the extent such instruction is required to be provided by
the Company.
5. In the event the coverage criteria or any Third Party Payor requirements
for a particular item are not met, the Company will, to the extent permitted
by law, charge the Responsible Party's credit or debit card on file with the
Company for the applicable ongoing rental, purchase or other authorized
charges, pursuant to the payment authorization above. If the Responsible
Party does not have a credit or debit card on file that can be charged by the
Company, or the Responsible Party otherwise fails to promptly make appropriate
payment arrangements, or fails to make any required payments, the Responsible
Party will return the Equipment to the Company in the condition specified in
this Agreement immediately (within 10 days) unless the Company determines the
Equipment cannot be returned without unreasonably endangering the patient; in
which case, the Company may exercise its rights described in Section 6, below.
6. If the Company determines that any Equipment for which payment has not been
properly arranged cannot be returned to the Company without unreasonably
endangering the patient, the Company may, at its option, transfer ownership of
such Equipment to the patient and charge the Responsible Party the remaining
Third Party Payor contract balance to purchase the same (or, if there is no
such balance, a purchase price reasonably determined by the Company, which
shall not exceed the Company's national retail charge for the item). The
return of such Equipment will not prevent the Company from pursuing any remedy
it may have against the Responsible Party to collect any amounts the
Responsible Party may owe to the Company.
7. Except to the extent required by applicable law, regulation or contract and
notwithstanding any other provision of this Agreement, (i) the Company is not
obligated to bill any Third Party Payor for any amounts owed on the patient's
account, and (ii) any submission of a claim to a Third Party Payor by the
Company is done solely for the convenience of the parties at the Company's
sole discretion and the Company may cease any or all billings to Third Party
Payors at any time and may instead bill the Responsible Party directly for any
or all amounts owed on the patient's account.
8. The Company may apply payments made on behalf of the patient to any
outstanding balance owed on the patient's account without regard to any
instructions accompanying the payment. Any unapplied overpayments made by or
on behalf of the patient will be refunded upon request, but will otherwise be
applied to the next accruing balance(s) due on the patient's account or to
other obligations of the patient as determined by the Company in its sole
1842 - X3934477 - CEU008

Printed: 10/20/21 14:38:44 Tax ID: 33-0057155
11
CEU008 NEED(999) 999-9999
1842 X3934477 SALYAK, VIKTOR 646 887-4188
10/19/21 APT 7H
FAR ROCKAWAY
(646) 887-4188 (718) 645-8901
JULIA
(718) 645-8901 M 70 255
discretion.
9. This Agreement does not revoke or rescind any prior or existing credit or
debit card or other payment authorization(s).
10. If I have previously canceled my authorization to charge any credit or
debit card for any monthly rental or other recurring fees listed on any
document signed by me or on my behalf for any products provided to me by the
Company that I have not yet returned to the Company, I hereby revoke that
cancellation and agree that all such products are included in the definition
of "Equipment" under this Agreement and that all such charges are included
in the definition of "Recurring Charges" under this Agreement. Accordingly,
I authorize the Company to charge any credit or debit card that the Company
may now or hereafter have on file for me for those Recurring Charges until
such Equipment is returned to the Company as provided in this Agreement.
By completing the card information below, I authorize the Company to charge

the specified card as described in this Agreement, including, but not limited
to, as described in the Payment Authorization section, above. If the card
information below is left blank or is incorrect or invalid, I authorize the
Company to charge any other credit or debit card I have already provided or
may subsequently provide to the Company for any payments I may owe to the
Company.
Credit/Debit Card Authorization: ____ Check here if the card is a DEBIT CARD
___________________________________________________ ____Visa ____Mastercard
Name on Card (exactly as printed) ____Amex ____Discover
__________________________________ _______________
Credit Card Number Expiration Date
___________________________________________ __________________________________
Billing Address (Street, Apt. #) City, State, Zip
1842 - X3934477 - CEU008

Printed: 10/20/21 14:38:44 Tax ID: 33-0057155

Apria Healthcare Private and Confidential

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Apria Healthcare Private and Confidential

Uploaded by

Copyright:

Available Formats

DocuSign Envelope ID: B9508B0B-25D3-41AD-A156-52296273FE88 APRIA HEALTHCARE LLC

2612 NE INDUSTRIAL DRIVE

Environment Suitable? Yes_ No_ N/A_

*-------- DELIVERY --------*

CONTINUES ON NEXT PAGE .....

1842 - X3934477 - CEU008

CONTINUES ON NEXT PAGE .....

1842 - X3934477 - CEU008

SUB-TOTAL .00 .00

Previous Outstanding Balance .00

For service or questions about your equipment call: 800-638-0942

CONTINUES ON NEXT PAGE .....

1842 - X3934477 - CEU008

FINANCIAL RESPONSIBILITY: I acknowledge that the coverage terms imposed by the

CONTINUES ON NEXT PAGE .....

1842 - X3934477 - CEU008

PAP PATIENT COMPLIANCE VERIFICATION:

My preferred (but not exclusive) method of communication from the Company

I acknowledge that communications by voicemail messages, text messaging and

If none of the above preferred communication methods is selected, I am

If a phone number or email address for a selected preferred communication

CONTINUES ON NEXT PAGE .....

1842 - X3934477 - CEU008

I acknowledge and agree that the preferred communication method(s) selected

CONTINUES ON NEXT PAGE .....

1842 - X3934477 - CEU008

This Agreement may be provided and signed in hardcopy or electronic (including

Note to Veterans Administration (VA) beneficiaries: To the extent the

COMMUNICATIONS: I acknowledge that communications by voicemail messages,

I understand that I am responsible for the payments described in this

CONTINUES ON NEXT PAGE .....

1842 - X3934477 - CEU008

In particular, I authorize the Company to charge my card for the amounts

RECURRING CHARGES. I acknowledge and agree that I am responsible for the

CONTINUES ON NEXT PAGE ..... Self

1842 - X3934477 - CEU008

condition specified in this Agreement, unless the Company determines the

REINSTATING PRIOR RECURRING CHARGES: If I have previously canceled my

I understand that the Recurring Charges I am authorizing under this Agreement

By signing this document, I acknowledge and agree, to the extent permitted by

CONTINUES ON NEXT PAGE .....

1842 - X3934477 - CEU008

CONTINUES ON NEXT PAGE .....

1842 - X3934477 - CEU008

By completing the card information below, I authorize the Company to charge

1842 - X3934477 - CEU008

You might also like

-------- DELIVERY --------