Respiratory Assist Device (RAD) Policy Medicare Beneficiary Statement
The Beneficiary Statement must be completed by the beneficiary, a family
member or caregiver within one month of seeing the treating physician
and at least 61 days after initiating use of the device. Information
captured on this statement must include: (1) patient's name, (2) date of
birth, (3) telephone number, (4) confirmation that the Medicare
beneficiary is using a machine that helps him/her take breaths during
sleep (separate from a machine providing oxygen or medicine), (5) stated
number of hours/day and number of months in total that the machine has
been used, (6) date of last visit with the physician who prescribed the
device, (7) confirmation that the device will be continued to be used
for treatment in the future, and (8) listing of who is answering the
questions. This statement must be signed and dated.
Patient/Beneficiary:___________________________________ Date of
Birth:____/____/_____ Patient/ Beneficiary Telephone Number: (_______) -
________ -___________ The Supplier May Not Answer Any Of the Following
Questions. 1. Are you (the Medicare Beneficiary) now using a machine
that helps you take breaths while you are asleep (separate from a
machine that may be giving you oxygen or medicine? YES NO 2. How many
hours a day do you usually use this machine? _________ HOURS 3. How many
months have you been using this machine? _________ MONTHS 4. When did
you last see the doctor who ordered this machine for you?
____/____/_____ 5. Will you keep using this treatment in the future? YES
NO 6. Did you (the Medicare beneficiary) complete answers #1 - 6? YES NO
If you did not answer these questions, who did and what is their
relationship to you?
NAME:___________________________________RELATIONSHIP:_________________________
_____________________________________________ _____/_____/______
Beneficiary Signature Date of Signature Respironics Page 1 Rev 10/22/99