Rental Intake Form

• After faxing or emailing please wait 25 minutes then call OxygenToGo® to confirm we have received your fax.
• The #1 reason for complaints is related to “Rush” orders. Please fully understand all costs before you submit forms.
• You must submit the airline Physician's Statement or, if not flying, a prescription from your doctor before we ship.
• OxygenToGo® does not bill any insurers including Medicare or Medicaid. An invoice will be provided upon request.
• The rental is delivered packaged within a shipping case. You MUST open that container immediately upon delivery.
• If you cancel the shipment after it has shipped you are responsible for return if FedEx still delivers to you.
• You must review our Cancellation Policy on pages 4 or 7. Non-use of equipment does not result in refund of fees.
• A minimum $50.00 is assessed for each missing item even if returned at a later date. Including the Pulse Oximeter.

Note: All efforts to ensure delivery will be made but any delays related to FedEx or a delivery service can't be guaranteed by OxygenToGo®. We highly suggest you give yourself 2+ days before departure.

• FAA battery requirements dictate that you have 150% of battery time for your flight time. A OxygenToGo® team member can assist you in ensuring correct battery for your transit.
• Shipping Charges – All shipping charges to and from the customer are billed to that customer!
• Due to the size of the fax, you may need to turn off your fax to reset the memory.
• How do I get the Portable Oxygen Concentrator (POC) unit? We ship the unit to the location noted on page one (1) of this document
• What should I take with me on the plane? Everything except for the shipping container and return label.
• What do I do with the shipping container the POC is/was delivered in? On a "round-trip" (the user will return where the device is first delivered to them), you would leave it at home. If a "one-way" (the user will not return to the location the device is first delivered to them), you would check it as a piece of luggage.
  Note: Do no attempt to take the shipping container into the passenger cabin.
• How do I return the POC unit? The box that you receive has a return FedEx return airbill. And for any reason you decide to use another carrier or another bill besides the one provided, you must notify OxygenToGo® with that new number. Follow the instructions and call with questions. Note: You are responsible for returning the unit. Please communicate with Nursing and Rehab centers clearly that if the unit is not picked up that you are notified.
• How do I make payment? Credit card is currently the only option for payment. Upon placement of the reservation we will charge the credit card and then again when the rental unit is shipped and/or returned.
• **We Do Not bill any insurance.** Not Government or private. Not Medicare or Medicaid.
• You should take multiple copies of the Physician’s Statement with you to the airport.
• Do I need a prescription? OxygenToGo® is required to have a Doctor’s prescription in order to supply you with any oxygen system. A fax copy of the prescription is acceptable. Fax 877-329-6994
• Do Not call your POC a “tank” or “tank of oxygen”. Doing so could delay your boarding.
• You are responsible for traveling with a sufficient supply of batteries to last the journey, per your oxygen requirements, including the duration of the flight, all ground time (before and after flight and during connections) and for unexpected delays. Consult your OxygenToGo®® agent for further information.
• How big is the shipping case? Around 18”x16”x18”.
• Does the unit only work on battery power? No, the rental unit also has a car adaptor and wall power cord that can power the device. All devices can use international power up to 240v, but you will need the physical plug adapter.
• Do you have rental terms shorter than one week? No, due to transport, usage, and cost of the rental package our shortest rental term is one week. Please review cancellation policy in the Rental Contract for refund information. Variation from policy will not be permitted under any circumstances unless in writing from OxygenToGo®.
• Can the user rely on the possibility that the aircraft has a power port or plug? No. FAA regulations don't mandate such a requirement from the airlines.
• Can I buy the rental unit? Yes, you can purchase the unit you have or a new unit. Call for details.
• How much is shipping? Depending upon transit service selected and distance, cost range $50 to $150+.
• You must notify the airline that a Portable Oxygen Concentrator (POC) unit will be used in flight
• If you cancel the rental shipment while in transit with FedEx it still may deliver to you or patient. If so you can either refuse it or, if it was delivered before you can refuse it, you need to call OxygenToGo® to ensure correct return of the rental device.
• After faxing please wait 25 minutes then call OxygenToGo® to confirm we have received your fax.

**$100/week additional for the iGo Continuous flow device.

Stipulated Equipment Value of Standard Rental Equipment: $3,500.00

Oxygen to Go, LLC, (hereinafter referred to as “OxygenToGo®”) agrees to rent to Customer (“Customer” is defined as both the payer and the user of the equipment if not the same), and Customer agrees to rent from OxygenToGo®, the Portable Oxygen Concentrator package, hereafter designated Equipment, described above, and except as otherwise provided herein, will continue until the end of the Effective Dates of Rental. The Customer agrees to use the equipment as directed by OxygenToGo®.

Shipping Charge(s) *Our default shipping service is 2 day. If Ground service falls within 2 days we may utilize.

OxygenToGo® will bill your credit card with the actual shipping costs when we ship the rental kit to the patient. OxygenToGo® will also bill customer for return shipping charges upon return of unit. If you ship via another carrier or another FedEx air bill number, you must call OxygenToGo® before to notify us of the changes. OxygenToGo® reserves the right to ship the rental to the customer renter at any point before the rental start date once rental agreement is submitted. Renter waives the right to deny any charges due to "no signature required" by the chosen delivery vendor of OxygenToGo®

Note: If you cancel the rental while in transit with FedEx it still may deliver to you or patient. If so, you can either refuse it or, if it was delivered before you can refuse it, you need to call OxygenToGo® to ensure correct return of the rental device.

Note: If you or anyone in your party cancel the rental shipment while in transit to you via FedEx or any other carrier you understand and take full responsibility that the shipment may still be delivered to you at the addressed noted on the Patient Intake. OxygenToGo cannot control the fact that FedEx or others vendors may fail to stop the shipment post tender to carrier. It is best to cancel the rental prior to departure.

Standard Equipment Provided in Rental

A/C, D/C Power supplies, if separate.

Three (3) rechargeable batteries minimum.

Users Guide and/or Quick Start Sheet.

Rolling Cart and/or soft carry case.

Pulse Oximeter

Additional Equipment available for Rental

a) Rechargeable battery - $40 per battery per week when rented with a POC kit.

The terms of this Agreement begins on the Effective Date, as shown on this contract, and except as otherwise provided herein, will continue until the equipment is returned to OxygenToGo® as noted in the terms of the effective date and return grace period.

Note: Rental period begins when you receive the device at your home and ends when OxygenToGo® receive the device back in our office. And due to the nature of FedEx or UPS, and the remote dispatching, the pick up of your rental unit is ultimately responsibility of the renter. OxygenToGo® reserves the right to ship the rental to the customer renter at any point before the rental start date once rental agreement is submitted. OxygenToGo does not require a direct signature for delivery on Federal Express. You must request a direct delivery signature service upon the submission of these rental forms to OxygenToGo®.

Cancellation Policy

If canceled one (1) week prior to our ship date, money returned in full minus $150.00 or 20% of total billable charges.

If canceled less than 24 hours prior to our FedEx pick up of 3 p.m. MST, half of money returned.

If canceled on the same day of shipping with FedEx, full rental and shipping charges apply. No exceptions and the day of shipping is at OxygenToGo's discretion.

Rental Charges Customer agrees to pay applicable rental charges and any other applicable fees IN ADVANCE prior to shipment to customer designated shipping address. A reserve is not a charge and Customer agrees to the acquisition of this reserve by signing this agreement. The Customer will return the Equipment at the end of the Rental Effective Date and will pay an equivalent daily rental rate based on the applicable rental rates for any time after the Effective Date. Until OxygenToGo® receives the Equipment in good condition, the Customer shall remain bound by the obligations of this Agreement.

Other Costs In addition to the applicable equipment rental charge and delivery charge, the customer also agrees to be charged for any additional equipment selected above and for shipping. The Customer agrees to pay OxygenToGo® any shipping costs for delivery of the Equipment to the Customer (as indicated above), and the Customer will pay for shipping costs for return of the Equipment to OxygenToGo®’s designated location. The Shipping charges noted above are for shipment to our home location in Jackson, Wyoming, USA. Additional charges apply for shipping to other locations at renter’s request. OxygenToGo® utilizes FEDEX or UPS for all rental shipments. If the customer returns the equipment via USPS, they will be assessed a $50.00 charge due to difficulty in recovery.

Security Deposit Reserve A reserve against the Customer’s credit card will be made as stated above on or before the Effective Date. This reserve will be maintained by OxygenToGo® and will be applied against any default of Customer in payment of rent or for damage or loss of the Equipment or other payment due OxygenToGo® which is chargeable to the Customer. Upon termination of this Agreement, and after final charges are paid in full, the reserve will be released from the credit card. Currently OxygenToGo® charges $3,500.00 in security deposit reserve. And if more than three (3) batteries provided, additional $450.00 per battery may be charged.

Test and (or) Repair Charge If returned equipment appears broken due to misuse, a test and repair charge of $50.00 may be charged for inspection, testing and minor repairs required to return the Equipment to service. This charge will be payable at the end of this Agreement. If the Equipment cannot be repaired, the customer will be notified and will be responsible for the designated replacement cost of the Equipment.

Taxes and Fees Customer will either pay directly for any taxes or governmental fees such as, use, property, excise, customs duty or other taxes, license fees, assessments, permits or commissioning and registration fees relating to the shipment, activation and rental of the Equipment. Smoking while using our equipment will be assessed a fee up to $2500.00.

Insurance OxygenToGo® does not insure the equipment during the period it is rented to the customer. The customer may elect to obtain, at higher expense, insurance covering the Equipment during the term of the rental. Optional Insurance coverage excludes loss due to shipping error or loss due to confiscation of Equipment by foreign government officials or by acts of terrorism. OxygenToGo® reserves the right to refuse insurance coverage in the event the equipment would be transported to a “high risk” area. An example of a “high risk” area would be transporting Equipment to Cuba.

Risk of Loss Customer will bear responsibility for all malfunctions, failures, damage to or loss of equipment, except to manufacturing defects and normal wear and tear covered under Section 9. In the event of any such damage or loss, Customer will promptly give OxygenToGo® notice thereof and, Customer will elect one of the following options:

• Pay to OxygenToGo® an amount equal to the Stipulated Equipment Value or fraction thereof for the damaged or lost equipment. In such case, the rental charges and other obligations of the Customer shall continue until the payment is made. After payment is made this Agreement will terminate as to the Equipment involved; or

• Request that OxygenToGo® repair or replace the damaged or lost equipment, and pay to OxygenToGo® the cost of such repair or replacement. In such case the rental charges and other obligations of the Customer shall continue during the period of repair or until replacement. If OxygenToGo® is unable to repair or replace the equipment then option (i) shall apply.

In any case the amount to be paid to OxygenToGo® shall be reduced by any applicable insurance proceeds paid to OxygenToGo® pursuant to Section 9.1 of this Agreement.

Early Returns Under no circumstance will customer be granted credit for unused time or early return of equipment as it pertains to the effective date of rental.

Export Regulations The Customer will not divert export or re-export the Equipment to any country contrary to U. S. export laws.

Excusable Delays If OxygenToGo’s performance of any obligation hereunder is delayed due to reasons beyond OxygenToGo’s reasonable control including acts of God, the time for performance of such obligation will be postponed for a period equal to the number of days of such delay. In no event will OxygenToGo® be liable for any damages resulting from any delay in the delivery of any Equipment or any delay in the performance of any maintenance.

Previous Agreements This Agreement supersedes all prior and contemporaneous agreements and representations made with respect to the same subject matter, and is the entire Agreement between the parties.

Severability In the event that any one or more provisions contained in this Agreement should, for any reason, be held to be unenforceable in any respect under the laws of the state of Wyoming, or the United States, unenforceability shall not affect any other provisions of this Agreement, but this Agreement shall be construed as if such unenforceable provision had not been contained herein.

Controlling Law All questions concerning the validity, operation, interpretation and construction of this Agreement will be governed by and determined in accordance with the laws of the Wyoming

Headings The headings and titles to the section and paragraphs of this Agreement are inserted for convenience only and will not be deemed a part hereof or affecting the construction or interpretation of any provisions hereof.

Counterparts This Agreement may be executed in one or more counterparts, each of which shall be deemed to be an original copy hereof.

Further Assurances The parties agree to perform all acts and execute all supplementary instruments or documents, which may be necessary or desirable to carry out the provisions of this Agreement.