Bemes Home Medical, Inc.
810 Sun Park Drive, Fenton, MO 63026
Phone: (877) 890-1100 Fax: (636) 343-1102
Portable Oxygen Concentrator Rental Agreement
Customer Name: _______________________________________________________
Customer Address: _______________________________________________________
__________________________________________________________________________
Home Phone: ____________________________________
Cell Phone: ______________________________________
Email Address: ___________________________________
Phyisican: ________________________________________________________________
Phone: __________________________________________
Liter Flow: _______________________________________
Diagnosis: ________________________________________________________________
Pulse Dose Compatible: Yes No Cancellation Policy: Yes No
Method of Payment: ______________________________________________________
Travel Destination: ________________________________________________________
Phone: __________________________________________
Address: _________________________________________________________________
Deliver by: _______________________ Date Returning: ______________________
Shipping Return: __________________________
Referred by: ______________________________________________________________
Airline: ___________________________________________
Current Provider: __________________________________________________________
Special Needs: ____________________________________________________________
Emergency Contact: _______________________________________________________
Phone: ___________________________________________
*** Please note that Rental is not guaranteed until contract is received by a Bemes Home Medical Associate and confirmed with the patient via email or telephone.
One Week (up to 7 days) = $199.00
Two Weeks (up to 14 days) = $299.00
Three Weeks (up to 21 days) = $399.00
Four Weeks (up to 28 days) = $499.00
* For every week ( up to 7 days) after, add $100.00
Extra Batteries are available for rental for $49.00 per battery/per week
*Shipping Charges are in addition to the rental charge*
The following standard equipment will be provided to the customer as part of this Agreement. Proof of delivery, and return will be provided for by both parties through execution of a delivery receipt or signed delivery via common courier. If additional equipment or accessories are provided or selected by customer, the Customer will pay additional rental charges.
Standard Equipment Provided in Rental
Inogen One:
SeQual Eclipse:
Respironics Evergo:
Stipulated Equipment Value of Standard Rental Equipment: $6,000.00
Section 2: Agreement to Rent
Bemes Home Medical (BHM) agrees to rent to the Customer (“Customer” is defined as both the payer and the user of the equipment if not the same), and Customer agrees to rent from BHM, the portable oxygen concentrator package, described above, and except as otherwise provided herein, will continue until the end of the Effective Dates of Rental.
SECTION 3: Terms
The terms of this Agreement begins on the date of delivery to the patient and except as otherwise provided herein, will continue until the equipment is received back at BHM.
SECTION 4: Payments
Rental Charges -Customer agrees to pay applicable rental and shipping charges IN ADVANCE prior to shipment to customer’s designated shipping address. If a credit/debit card is used for payment, the card will be charged the day prior to shipping, to ensure adequate funds available. If a home care provider or other agency is to be billed, an itemized statement will be faxed to the company the day the unit is shipped. The Customer will return the Equipment at the end of the Rental Effective Date agreed upon at time of contract. Until BHM receives the Equipment in good condition, the Customer shall remain bound by the obligations of this Agreement.
Late Charges:
The equipment will be considered late if not shipped back on the agreed upon date. This date will be agreed upon at the time of rental. It is the customer’s responsibility to notify BHM if the equipment is not going to be returned on the agreed upon dated. If the unit is not received late charges will be as follows:
$199.00 per 1-7 days the unit is late$49.00 per battery every 1-7 days the item is late
Test and/or Repair Charge:
If returned equipment appears broken due to misuse, a test and repair charge of $50.00 may be charged for inspection, testing and minor repairs required to return the Equipment to service. This charge will be payable at the end of this Agreement. If the Equipment cannot be repaired, the customer will be notified and will be responsible for the designated replacement cost of the Equipment. The estimated value of the unit is $6000.00.
Other Charges:
In addition to the applicable equipment rental charge and delivery charge, the customer also agrees to be charged for any additional equipment selected above and for shipping. The Customer agrees to pay BHM any shipping costs for delivery and return of the Equipment (as indicated above). The Shipping charges are noted above.
There will also be a $15.00 charge if the User’s Manual is not returned to BHM.
SECTION 5: Cancellation Policy
If the reservation is cancelled 8 or more days prior to the delivery date, a $50 cancellation fee will be charged. If the reservation is cancelled 7 days or less of the delivery date, a fee equal to one week’s rental will be charged ($199.00).
SECTION 6: Ownership and Security Interests
Ownership-Customer acknowledges that BHM is and shall remain the owner of the Equipment. Customer will protect BHM ownership rights against claims, liens and other encumbrances by Customer’s creditors or other claimants against Customer. Customer will not remove, obliterate or obscure markings, which identify BHM as owner of the Equipment.
SECTION 7: Insurance and Risk of Loss
Insurance -BHM does not insure the equipment during the period it is rented to the customer. BHM will only be responsible for equipment malfunctions if they are due to manufacture defects and normal wear and tear. Any damages that fall outside of this range will be the Customer’s responsibility. While in the possession of the Customer, if the equipment is lost, stolen, or damaged BHM will not be responsible for providing replacement equipment. We may be able to assist you in obtaining backup equipment, but extra fees will apply.
SECTION 8: General
Item to be Rented: ______________________ Total Charge: ________________
Extra Batteries Rented: ______________________ Total Charge: ________________
Total Shipping Charge: ______________________ Ground or Overnight
Delivery Date: ________________________________
Return Shipping Date: ________________________________
Delivery Address: ________________________________________________________________________
______________________________________________________________________________________________AGREED TO By:
______________________________________ Date ___________________
Customer Signature
______________________________________
Customer Name Printed
Received back to BHM on ________________ by ____________________________