Medicare Beneficiary Statement

Evaluation of Respiratory Assist Device

Beneficiary Name ________________________ Birth Date __/__/__/

Beneficiary telephone number (____) - __ __ __ - __ __ __ __

The Supplier May Not Answer Any Of The Following Questions

1. Are you now using a machine (called CPAP) that helps you take your breaths while you are asleep?

YES NO ( circle answer)

2. Do you use this machine for more than four hours per day?

YES NO ( circle answer)

3.How many months have you been using this machine?

_________ Months

4. When did you last see your doctor who ordered the machine for you?

____/____/_____

5. Will you keep using the machine in the future?

YES No (circle answer)

If you, the beneficiary , did not answer the questions, who did? ( example spouse, caregiver)

Name:_____________________ Relationship:_________________

Beneficiary

Signature: ____________________ Date:_____________

(rsi-cpap.3)