If you, the patient, have signed for Proof of Delivery with UPS/ FedEx, please do not complete this form.

Thank you for choosing Tyler Medical Services LLC!

By signing in the space provided below, I hereby acknowledge receipt of supplies on the packing slip attached. I have authorized Tyler Medical Services LLC, my appointed supplier, to bill and receive payment from Medicare, Medicaid, Insurance Companies, and/or its agents and/or assigns for the supplies I have received. No other company has my consent to ship me and/or bill on my behalf.

Your feedback is very important to Tyler Medical Services LLC. You may be contacted by phone, SMS text, email, or mail to complete a Patient Experience Survey. Terms of data privacy apply your consent to use your personal information for business processing, including sharing your information with third parties.
If you do not wish to participate in providing feedback in our Patient Experience Surveys or have concerns about the collection of your personal data that may interfere with your right to privacy, please select the opt-out option on the Acknowledgement Form provided in this Welcome Packet.

Every product sold or rented by our company carries a 1-year manufacturer’s warranty. Tyler Medical Services LLC will notify all Medicare beneficiaries of the warranty coverage, and we will honor all warranties under applicable law.
Tyler Medical Services LLC will repair or replace, free of charge, Medicare-covered equipment that is under warranty. In addition, an owner’s manual with warranty information will be provided to beneficiaries for all durable medical equipment where this manual is available

Tyler Medical Services LLC will provide patients, caregivers, customers, facilities and referrals with general information concerning our staff and time frame for completing physician orders and delivery times.

Patient Rights:

• The patient has the right to considerate and respectful service.
  The patient has the right to obtain service without regard to race, creed, national origin, sex, age, disability, diagnosis or religious affiliation.
• Subject to applicable law, the patient has the right to confidentiality of all information pertaining to his/her medical equipment service. Individuals or organizations not involved in the patient’s care, may not have access to the information without the patient’s written consent.
• The patient has the right to make informed decisions about his/her care. The patient has the right to reasonable continuity of care and service.
• The patient has the right to voice grievances without fear of termination of service or other reprisal in the service process.

Patient Responsibilities:

• The patient should promptly notify the Home Medical Equipment Company of any equipment failure or damage.
• The patient is responsible for any equipment that is lost or stolen while in their possession and should promptly notify Home Medical Equipment Company in such instances.
• The patient should promptly notify the Home Medical Equipment Company of any changes to their address or telephone.
• The patient should promptly notify the Home Medical Equipment Company of any changes concerning their physician.
• Except where contrary to federal or state law, the patient is responsible for any equipment rental and sale charges which the patient’s insurance company/companies do not pay.

Tyler Medical Services LLC has created this statement in order to demonstrate our firm commitment to privacy. We believe that strong electronic privacy is crucial. Therefore, unless you designate otherwise, any information collected will be known only to you and Tyler Medical Services LLC. We pledge thatTyler Medical Services LLC will not release your personal data to anyone else without your consent – period.
Contact information may be used occasionally by Tyler Medical Services LLC to notify you of new products and services, recalls on products previously purchased, or products maintenance, but will not be given or sold to third parties. When we do present user information to our advertisers or audience, it is in the form of statistical compilations of data from visitors’ answers to survey questions as well as grouped on-site behavior. Financial information that is collected is used only to bill for products and services but is never released to anyone without a “need to know,” for any reason.

After Hours, Please leave a voicemail and a representative will respond the next business day

MEDICARE DMEPOS SUPPLIER STANDARDS DMEPOS suppliers have the option to disclose the following statement to satisfy the requirement outlined in Supplier Standard 16 in lieu of providing a copy of the standards to the beneficiary.
The products and/or services provided to you by Tyler Medical Services LLC are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained at https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part- 424/subpart-D/section-424.57. Upon request we will furnish you a written copy of the standards.

You have received instructional application brochures on the proper use of the equipment, through a demonstration located on our manufacturers’ website at www.ddpmedical.com along with printed material, should you have questions regarding any possible warnings and contraindications. Furthermore, you understand that as per your written physician prescription, Tyler Medical Services LLC will automatically coordinate the level of supplies that you may require.

I request that the payment of authorized benefits be made on my behalf to Tyler Medical Services LLC, for products and services that they have provided me. I further authorize a copy of this agreement to be used in place of the original release to other payors, any information needed to determine these benefits or compliance with current healthcare standards.

I authorize and direct you, my attorney, and or insurance company to pay directly to Tyler Medical Services LLC such sums that may be due for services rendered. In the event that my insurance company has a preferred provider that is considered in network, I instruct my insurance company to apply my out of network benefits. I further give a lien on my case to Tyler Medical Services LLC against any and all
proceeds of any settlement, judgment, or verdict that may be paid to you, my attorney, or me.

I authorize Tyler Medical Services LLC to use your recorded electronic signature as your “Authorization of Benefits” to bill your insurance carrier for the equipment prescribed by your physician. This consent is specifically to permit an electronic signature acquired by the United Parcel Services in lieu of hand-written signatures on any one or more of the documents you have received.

Tyler Medical Services LLC consents to accept your electronic signature as true, correct and binding to enter into the billable transaction in reliance thereon.

You have the right to freely voice grievances and recommend changes in care or services without fear of reprisal or unreasonable interruption of services. Service, equipment, and billing complaints will be communicated to management and upper management. These complaints will be documented in the Medicare Beneficiaries Complaint Log, and completed forms will include your name, address, telephone number, and health insurance claim number, a summary of the complaint, the date it was received, the name of the person receiving the complaint, and a summary of actions taken to resolve the complaint. All complaints will be handled in a professional manner. All logged complaints will be investigated, acted upon, and responded to in writing or by telephone by a manager within five (5) days and resolved within fourteen (14) days. If there is no satisfactory resolution of the complaint, the next level of management will be notified progressively and up to the president or owner of the company. To report a complaint regarding the services you receive, please call the Texas State Abuse Hotline Number at 800-252-5400 or CMS (Centers for Medicare/Medicaid Services) directly at 800-633-4227.

Organization must include Board of Certification’s statement within written information provided to customers/patients on the complaint process. Documentation is maintained in the Medical Record. Statement: “In the event your complaint remains unresolved with Tyler Medical Services LLC you may file a complaint with our Accreditor, Board of Certification via their website www.bocusa.org or via phone telephone at 877-776-2200.

Tyler Medical Services LLC is processing the enclosed durable medical equipment that has been prescribed by a licensed medical professional.

The purpose of this packet is to inform you of your order, patient rights and responsibilities along with valuable information concerning other health care issues.

Our mission is to build trusting relationships with patients, families, physicians, and all others devoted to patient care in the home.

Working as a team, we wish to provide you with quality health care to speed your recovery. Together we can help you reach your maximum potential.

Please note our return policy:

A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.

Purchased equipment that does not meet the needs of the patient may be returned to Tyler Medical Services LLC within thirty (30) days from date of delivery with the approval of Tyler Medical Services LLC:

• Has not been modified or repaired by someone other than an authorized representative.
• Replacement equipment will be provided when necessary/requested.
• Equipment will not be accepted that has been used or to which unauthorized modifications or repairs have been made.

After Hours, Please leave a voicemail and a representative will respond the next business day.
Hours of operations: Monday to Friday, 10am-4pm

We trust you will find great value in the products you have received. Our company bills CMS according to the 2025 Medicare Fee Schedules when processing your claim. We only bill for the products your physician has prescribed, and you will see those amounts reflected in your Explanation of Benefits you receive from Medicare and your Secondary Insurance Company.

You may, however, be responsible for the deductible and coinsurance amounts not covered by your insurance provider, depending on secondary insurance or financial hardship. You may be invoiced for any remaining balance.

Should you have a remaining balance our company will provide you with four different payment options to choose from, as referenced below. Please allow 4-6 weeks processing time from the date of delivery.

• Option #1 – Secondary Insurance
• Option #2 – Pay balance by Credit Card
• Option 3#-Pay balance in instalments

Our company bills for products and services in accordance with Medicare fee schedule guidelines.
By accepting, receiving, and electronically signing for products and services delivered by UPS/FEDEX, under penalty of perjury, you have provided true and accurate information regarding the processing of this claim. Proof of delivery is one of the supplier standards as noted in 42 CFR, 424.57(12). Proof of delivery documentation must be made available to Medicare upon request. Your Proof of Delivery signature will include acknowledgment of the following documents:

• CMS Supplier Standards
• Instructions for use
• Assignment of Benefits
• Protocol for Resolving Complaints
• Patient Experience Surveys
• Equipment Warranty Information
• Beneficiary Information – Rights and Responsibilities
• HIPAA Privacy Notice