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Patient Information
First Name:Last Name: Middle: DOB:
Address: Phone Number: Sex:Height: Weight: Email

Physician’s Information
First Name:Last Name: NPI# Phone Number: Diagnosis Code/Description:

Equipment Delivery
Duration: month(s) supplyStarting: Ending:

HCPCS	*ST	Equipment/Supplies	Qty	Make	Model	Serial #

*ST–Sale Type([NU]New Equip/[NB]Non-Billable/[RR]Rental/[UE]Used Equip)We accept Medicare assignments

Assignment Agreement
I have received equipment as prescribed , meet the need , training, instructions for proper use & maintenance. I authorize for medical or other information necessary (1) to obtain from your physician and (2) release to process this claim. I authorize payment of government benefits or other insurance benefits to Dusara Corporation dba UniversalMed Supply. I authorize UniversalMed Supply to use and keep on file my signature to be used for billing and in block 12 & 13 of the CMS-1500 form. I agree to pay any remaining co-payments, deductible amounts or denied-payments to Dusara Corporation. I acknowledge receipt of (1) Patient Handbook (warranty information complaint protocol, & how to obtain supplier standards (2) Residence Assessment info. I authorize UniversalMed Supply to contact through various methods (phone, email, text, etc.) regarding my equipment and/or supplies/re-supplies. I acknowledge receipt of oxygen back-up system and instructions to use it only during emergencies (for oxygen patients only).

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Residence Assessment
Heater near oxygen equipment Cluttered household No smoke detector No smoke detector No smoke detector No smoke detector No smoke detector No smoke detector No smoke detector No smoke detector No smoke detector No smoke detector
Delivery Instructions Address:Room#:Contact Name:Contact Number:
Printed Name:Signature:Relationship:
Technician Name:Signature:Delivery Date::