Let’s work together.DME Proof of Delivery Patient InstructionMedical Logistics Solutions Name * Date MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Alterate Phone * (###) ### #### OTHER HOME CARE SERVICES EQUIPMENT Make & Model Lot/Serial # Amount Billed to Insurance : Approximate Co-Pay TYPE OF PRODUCT Lumbar Brace LSO Type 1 Lumbar Brace LSO Tpye lll Lumbar Belt Brace Cervical Hard Collar Cervical Soft Collar L-O648 L-O648 L-O642 L-O172 L-O174 L-O180 Small Medium Large Other Thank you!
