CMS Pub. 100-04, ch. 20, § 30.5.3.1

Exhibit 1 - The Rent/Purchase Option

You have been renting your (specify the item(s) of equipment) for 10 continuous rental

months. Medicare requires (specify name of supplier) to give you the option of

converting your rental agreement to a purchase agreement. This means that if you accept

this option, you would own the medical equipment. If you accept the purchase option,

Medicare continues making rental payments for your equipment for 3 additional rental

months. You are responsible for the 20 percent coinsurance amounts and, for unassigned

claims, the balance between the Medicare allowed amount and the supplier's charge.

After making these additional rental payments, title to the equipment is transferred to

you. You have until (specify the date one month from the date the supplier notifies the

patient of this option) to elect the purchase option. If you decide not to elect the purchase

option, Medicare continues making rental payments for an additional 5 rental months, a

total of 15 months. You are responsible for the 20 percent coinsurance amounts and, for

unassigned claims, the balance between the Medicare allowed amount and the supplier's

charge. After a total of 15 rental months have been paid, title to the equipment remains

with the medical equipment supplier; however, the supplier may not charge you any

additional rental amounts.

In making your decision to rent or purchase the equipment, you should know that for

purchased equipment your supplier may charge you each time your equipment is actually

serviced. You are responsible for the 20 percent coinsurance amounts and, for

unassigned claims, the balance between the Medicare allowed amount and the supplier's

charge. However, for equipment that is rented for 15 months, your responsibility for

such service is limited to 20 percent coinsurance on a maintenance and servicing fee

payable twice per year whether or not the equipment is actually serviced.

Exhibit 2 - How Medicare Pays For Electric Wheelchairs

(Rev. 1, 10-01-03)

If you need an electric wheelchair prescribed by your doctor, you may already know that

Medicare can help pay for it. Medicare requires (specify name of supplier) to give you

the option of either renting or purchasing it. If you decide that purchase is more

economical, for example, because you will need the electric wheelchair for a long time,

Medicare pays 80 percent of the allowed purchase price in a lump sum amount. You are

responsible for the 20 percent coinsurance amounts and, for unassigned claims, the

balance between the Medicare allowed amount and the supplier's charge. However, you

must elect to purchase the electric wheelchair at the time your medical equipment

supplier furnishes you the item. If you elect to rent the electric wheelchair, you are again

given the option of purchasing it during your 10th rental month.

If you continue to rent the electric wheelchair for 10 months, Medicare requires (specify

name of supplier) to give you the option of converting your rental agreement to a

purchase agreement. This means that if you accept this option, you would own the

medical equipment. If you accept the purchase option, Medicare continues making rental

payments for your equipment for 3 additional rental months. You are responsible for the

20 percent coinsurance amounts and, for unassigned claims, the balance between the

Medicare allowed amount and the supplier's charge. After these additional rental

payments are made, title to the equipment is transferred to you. You have until (specify

the date one month from the date the supplier notifies the patient of this option) to elect

the purchase option. If you decide not to elect the purchase option, Medicare continues

making rental payments for an additional 5 rental months, a total of 15 months. After a

total of 15 rental months have been paid, title to the equipment remains with the medical

equipment supplier; however, the supplier may not charge you any additional rental

amounts.

In making your decision to rent or purchase the equipment, you should know that for

purchased equipment, you are responsible for 20 percent of the service charge each time

your equipment is actually serviced and, for unassigned claims, the balance between the

Medicare allowed amount and the supplier's charge. However, for equipment that is

rented for 15 months, your responsibility for such service is limited to 20 percent

coinsurance on a maintenance and servicing fee payable twice per year whether or not the

equipment is actually serviced.