Rental and Purchase of an Electro Stimulator

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1.   2 months rental supplies included  Monthly rental price $33.38
   Your 20% is $6.68 per month      _____1 month rental     _____2 month rental
   
2. 3rd month purchase or return to rep.
   Purchase price $333.81 Your 20% is $66.77 Supplies are included in the
   3rd month,
   
3. 4th month monthly supplies start. 2 kits $51.90 Your 20% is $10.38 per month
   
4. You have a $100.00 deductible. If this deductible is not met, you are responsible for
   payment of this deductible.
   
5. Medicare pays 80% of the rental, purchase and supplies. You are responsible for the other
   20%. If you have Medicaid or a Medigap insurance policy, then these insurance companies
   will pick up a portion or all of the remaining 20%.
   
6. If you agree to purchase the Electro stimulator unit and the rental period is over, we will
   waive the rental price until Medicare notifies us of their decision to purchase the unit or not.

I have read and understand the MedCare Service. terms and procedures and I agree to pay any unpaid ballance incurred by my use of the Electro stimulator. I authorize MedCare Services, to secure payment of said benefits from myself, Medicare, Medicaid, and any Medigap insurance policy that I am bificiary to.