Dear Patient and Family:

Your physician has ordered/recommended a Respiratory Assist Device (CPAP/BIPAP) after you leave the hospital.

St. Vincent`s Durable Medical Equipment, which is owned in part by St. Vincent`s Health System, can provide the services or supplies ordered/recommended by your provider.

You have the right to select any provider to provide the care ordered/recommended by your physician. This is your choice.

Patient or Family, please check one of the following:

In compliance with our policy, the absence of an affirmative choice by the patient or representative, the default is to the ST. VINCENT`S DURABLE MEDICAL EQUIPMENT.

List the best number for the Provider to use when contacting you:

Patient or Responsible Party (State Relationship)                        Date

St. Vincent`s Sleep Disorders Center Representative                  Date

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Document name: CPAP/BIPAP Equipment Choice List

Unique Document ID: e0ee59175159739b70a16c87ddcc9095c9cf2a23

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Timestamp	Audit
January 25, 2021 12:01 pm CDT	CPAP/BIPAP Equipment Choice List Uploaded by Dylan Richardson - dylan@danmarkcom.com IP 12.233.60.59

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