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Printed Date: 9/22/2015
The attached model forms were created in an effort to educate suppliers regarding certain supplier standards listed in 42 CFR.424.57(c).
Please note that these forms are simply templates and suppliers should feel free to create their own forms. Suppliers using their own forms must ensure the forms are capturing and documenting information as required by the supplier standards.
The 'Model Warranty Information Form' addresses supplier standard #6, which requires the supplier to inform Medicare beneficiaries about the warranty coverage of any piece of equipment or any supply provided. The text of the standard reads as follows:
The 'Model Complaint Resolution Protocol' form addresses standard #19, which requires the supplier to have a protocol in place to resolve complaints received from Medicare beneficiaries regarding services rendered. The text of the standard reads as follows:
The 'Model Complaint Log Sheet' addresses standard #20, which requires the supplier to log certain specific information about complaints received from Medicare beneficiaries. The text of the standard reads as follows:
The final form addresses supplier standard #5, which requires suppliers to advise beneficiaries of the rent/purchase option for capped and inexpensive or routinely purchased items. The text of the standard reads as follows:
Should you have any questions or comments about these forms, please feel free to contact the NSC at (866) 238-9652. To access or download each of the model forms, open the links below.
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Last Updated: 08/12/2016
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