Please Note: There is no Medicare information on our corporate website. Please select a specific contract in the 'Search Within' box for Medicare related information.
© 2021 Palmetto GBA, LLC
We frequently update our articles to reflect the latest changes and updates to Medicare, and strongly recommend you visit this article at link below to confirm you have the latest version.
Published Date:08/12/2016
Printed Date: 9/22/2015
URL: http://palmgba.com/marlowe/redesign6/article.html
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.
We value your opinion and want to provide the highest-quality and most relevant Medicare knowledge possible. Please let us know if this article was helpful.
It didn't answer my question This article was helpful
We’re glad we could help you today and appreciate your feedback. When you rate our articles as most helpful, we know that we are on the right track for providing you with important news and information.
We're sorry this article didn't help you today. We'll use your feedback to review this article to try to revise or expand it. Contact us with more feedback or a question on this topic.
Last Updated: 08/12/2016
We've recently uppgraded our website and it looks you're trying to access an old link. Please select an option below.
Attempt to load this page on new site
Go to Home page
Go to Contact Us page
View a related article: