VIVE ELECTRIC SCOOTER PURCHASE AGREEMENT $845
Knee Walker Rentals of Georgia, Inc.
1251 Julie Court
Riverdale, Ga. 30296
678-858-5922 OFC 888-789-4160 FAX
PARTIES INVOLVED IN THIS PURCHASE AGREEMENT
SELLER/DISTRIBUTOR: The distributor selling the DME property (Vive scooter) Knee Walker Rentals of Georgia, Inc, dba DME of Georgia, Inc. herein referred to as “Seller”.
PURCHASER: The individual or company executing this purchase agreement and making payment to complete the purchase, herein referred to as "Purchaser".
PURCHASE AGREEMENT TERMS AND CONDITIONS
PURCHASE TERMS: All Vive scooters sold are new, whether delivered in or out of box, based on “Purchaser” preference. The sales date of this agreement shall be the date the new Vive scooter is delivered to the "Purchaser" premises by “Seller.” and payment is made and received. Neither the sale or the sales date of this purchase agreement can/shall be canceled or rescinded by either party after 12 hours of the delivery time and date. If the “Purchaser” contacts the “Seller” informing that the purchased Vive scooter is needing to be returned within 12 hours of the delivery time and date to “Seller”, the “Seller” will make the pickup of the returned Vive scooter. If the return is due to undesired expectations, improper fit, safety and/or manufacturer’s defect, the “Seller” will refund the amount paid, minus the delivery fee (Avg. $75-100), within 24 hours of Vive scooter return. A warranty brochure from the manufacturer, Vive Health, accompanies all deliveries of the new Vive scooter and is provided to the “Purchaser” on delivery.
INSPECTION: "Purchaser" acknowledges that their new Vive scooter was inspected and examined by "Puchaser" prior to acceptance and signing the Purchase Agreement. “Purchaser” also acknowledges their Vive scooter was found to be in undamaged and in good working condition at the delivery time and date. "Purchaser" further acknowledges that the proper safe usage and breakdown of their Vive scooter was educated and demonstrated to the “Purchaser” on the delivery appointment and the “Purchaser demonstrated their full understanding of the proper setup, breakdown and usage of their new Vive scooter. "Purchaser" further acknowledges their duty to inspect the Vive scooter prior to use and notify “Seller” of any defects. If within 12 hours of the delivery time and date, any defects are found or in a state of disrepair "Purchaser" will immediately discontinue usage and contact “Seller” for
further instructions. “Seller” will promptly make arrangements for a return of the Vive scooter to the “Purchaser”. If within 12 hours of the delivery time and date, “Purchaser” agrees to use reasonable effort to either replace the Vive scooter with similar property in good working condition or arrange a refund as soon as possible. IMPORTANT: PLEASE FULLY INSPECT YOUR VIVE SCOOTER IMMEDIATELY UPON RECEIPT OF THE ITEM AND NOTIFY SELLER OF ANY DAMAGE OR DEFECTS WITHIN 12 HOURS OF THE DELIVERY TIME/DATE. ANY DAMAGE SUSTAINED AFTER THE 12 HOUR DELIVERY TIME/DATE WILL BE REPORTED TO THE MANUFACTURER, VIVE HEALTH (239) 220-5772, FOR INSTRUCTIONS AND IF NEEDED, WARRANTY WORK.
BODILY INJURY AND PROPERTY DAMAGE RESPONSIBILITY: “Seller” provides nor assumes any BODILY INJURY or PROPERTY DAMAGE LIABILITY INSURANCE or coverage to “Purchaser” or any other operator or user for bodily injury or property damage to/from the Vive scooter. "Purchaser" agrees to defend, indemnify and hold “Seller” harmless from any claims, liabilities, costs and expenses arising from the "Purchasers” use, operation or possession of the Vive scooter.
PAYMENT: "Purchaser" agrees that payment in full ($845.00)
will be paid in cash or check, money order/official check made payable to
“Seller.” upon execution of this Purchase Agreement. Unless stipulated otherwise, “Purchaser” acknowledges that a shipping/delivery fee (Avg. $75-100), is included in the $845 purchase price, as deemed applicable, based on distance of the delivery. Above rates do not include any applicable taxes.
TITLE TO PURCHASED PROPERTY: After 12 hours of the delivery time and date, title to the Purchased Property, the new Vive scooter, will at all times remain with the “Purchaser” unless there is a future sale of the Vive scooter to another person or entity.
COLLECTION COSTS: In the event that “Seller” must resort to litigation to obtain Sale charges, Returned check charges or any and all other monies due from "Purchaser", "Purchaser" agrees to pay attorney's fees, court costs and other expenses which are incurred by “Seller” as a result, directly or indirectly, of “Seller’s” entering into this Purchase Agreement with "Purchaser".
SEVERABILITY: The provisions of this Purchase Agreement shall be severable so that the invalidity, unenforceability or waiver of any of the provisions shall not affect the remaining provisions.
MINIMUM AGE: The minimum age to execute this Purchase Agreement is 18 years of age, proven with Presentation and Photographing of a valid, current state identification or passport.
CANCELLED RESERVATIONS: "Knee Walker Rentals of Georgia, Inc dba DME of Georgia, Inc., aka “Seller “Seller” will not be held responsible for cancellation of sale due to depletion of inventory beyond “Seller’s” control. This Purchase Agreement may be canceled at any time by either party prior to the physical shipment/delivery of the new Vive scooter. However, this Purchase Agreement is binding and may not be canceled for any reason 12 hours after order is delivered, received and full payment is made and accepted by “Seller”.” By signing this Purchase Agreement, “Purchaser” confirms either having read the Purchasing Agreement online (http://www.kneewalkerrentalsofga.com/)and agree to the terms of this Purchase Agreement, a legal sales document or was offered the opportunity to read and/or copy the full Purchase Agreement upon delivery of their new Vive scooter. “Purchaser” agree to contact “Seller” immediately for any defects, repairs, etc., within 12 hours of delivery time and date. “Purchaser” has read, reviewed and agreed to the full terms of this Purchase Agreement, as indicated by signing the following final page of this Purchase Agreement. IF APPLICABLE, “Purchaser” may use a copy of this agreement for possible reimbursement through their insurance company. I acknowledge that “Seller” is not in-network with any insurance carrier/coverage and will not file the Purchase Agreement to the “Purchaser’s” private insurance company, Medicare and/or Medicaid. If desired, “Purchaser” acknowledges that ANY filing with their personal insurance, Medicare and/or Medicaid is their full responsibility.
KNEE WALKER RENTALS OF GEORGIA, INC. PURCHASE AGREEMENT/APPROVAL FORM
PURCHASER’S SIGNATURE /APPROVAL OF PURCHASE AGREEMENT TERMS*__________________________________________________________
: *BY SIGNING ABOVE, I AGREE TO THE PURCHASE AGREEMENT TERMS AND MY PHOTO AND DRIVER’S LICENSE COPIED AND/OR PHOTOGRAPHED)
DATE OF BIRTH: ___________________________________________________
CITY: STATE: ZIP:__________________________________________________
HEIGHT: ______WEIGHT: ______LBS INJURY: R / L BOTH GENDER: FEMALE / MALE
DRIVER’S LICENSE/ID #: ______________STATE: ___________DATE OF ISSUE:______________________
DRIVER’S LICENSE/ID DATE OF EXPIRATION:_________________________ EMAIL ADDRESS:__________________________________________________
BEST PHONE#: ________________CELL PHONE/ALT:___________________
DATE(S) OF ELECTRIC SCOOTER PURCHASE: _________________________ HCPCS CODE: K0003/1230
ANTICIPATED USAGE PERIOD NEEDED (WEEKS): 99 WEEKS=PURCHASE*
MOBILITY BRAND/MODEL BEING PURCHASED:________________________
DEPOSIT/AMOUNT PAID: $____/ $_________PAYMENT TYPE: _____________ TRANS#_________________________________________________________
***ONLY FOR CLIENTS SEEKING REIMBURSEMENT FROM INSURANCE***
INSURANCE COMPANY:___________PRIOR AUTHORIZATION NEEDED: Y / N
ID/MEMBER #:_____________GRP #:______________PHONE #:____________
MEDICARE: Y / N HICN#_____________ EFF. DATES: A/B:
INFORMATION BELOW TO BE ENTERED BY PHYSICIAN, PA, PHYSICIAN’S EMPLOYEE
PRIMARY DIAGNOSIS / APPLICABLE ICD-10 CODE(S):___________________
ESTIMATED LENGTH OF NEED (# IN WEEKS/MONTHS)* 99 WEEKS=PURCHASE*
PHYSICIAN’S CERTIFICATION:AFTER A COMPLETE, COMPREHENSIVE EVALUATION OF THIS PATIENT, I CERTIFY THE DURABLE MEDICAL EQUIPMENT/SUPPLIES LISTED ABOVE IS MEDICALLY NECESSARY, BASED ON THE APPLICABLE MEDICAL ICD-10 CODES EXPRESSED ABOVE.
PHYSICIAN’S OR PA-C NAME: ____________________NPI#:_______________
CITY, STATE, ZIP: _____________________PHONE: _____________________ FAX:_____________________________________________________________
PLEASE SIGN, FILL IN APPLICABLE ICD-10 CODES AND FAX TO KNEE WALKER RENTALS OF GEORGIA, INC.
1-888-789-4160 FAX 678-858-5922 OFFICE