"Affidavit for Licensing as a Durable Medical Equipment Supplier" - Colorado

Affidavit for Licensing as a Durable Medical Equipment Supplier is a legal document that was released by the Colorado Secretary of State - a government authority operating within Colorado.

Form Details:

  • Released on November 5, 2015;
  • The latest edition currently provided by the Colorado Secretary of State;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Secretary of State.

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Download "Affidavit for Licensing as a Durable Medical Equipment Supplier" - Colorado

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Affidavit for Licensing as a Durable Medical Equipment Supplier
Colorado S ecretary of State
I,
, solemnly affirm, under the penalty of
perjury in the second degree, as defined in section 18-8-503, C.R.S., that:
1. I am authorized to submit a Durable Medical Equipment Supplier License Application,
including this Affidavit, on behalf of Applicant
;
2. Applicant has at least one accredited physical facility that is staffed during reasonable
business hours and is within one hundred miles of any Colorado resident Medicare
beneficiary being served by the Applicant;
3. Applicant has sufficient inventory and staff to service or repair products; and
4. Applicant is accredited by an accrediting organization recognized and accepted by the
Federal Centers for Medicare and Medicaid Services.
Authorized individual’s signature:
Authorized individual’s title or position:
Date:
A notary public or other qualified person must co mplete the following section.
Subscribed and affirmed before me in the county of
, state of
this
day of
, 20
.
Official signature of Notary Public or other qualified person
[seal]
Commission expiration date
Affidavit
Page 1 of 1
Rev. 11/05/2015
Affidavit for Licensing as a Durable Medical Equipment Supplier
Colorado S ecretary of State
I,
, solemnly affirm, under the penalty of
perjury in the second degree, as defined in section 18-8-503, C.R.S., that:
1. I am authorized to submit a Durable Medical Equipment Supplier License Application,
including this Affidavit, on behalf of Applicant
;
2. Applicant has at least one accredited physical facility that is staffed during reasonable
business hours and is within one hundred miles of any Colorado resident Medicare
beneficiary being served by the Applicant;
3. Applicant has sufficient inventory and staff to service or repair products; and
4. Applicant is accredited by an accrediting organization recognized and accepted by the
Federal Centers for Medicare and Medicaid Services.
Authorized individual’s signature:
Authorized individual’s title or position:
Date:
A notary public or other qualified person must co mplete the following section.
Subscribed and affirmed before me in the county of
, state of
this
day of
, 20
.
Official signature of Notary Public or other qualified person
[seal]
Commission expiration date
Affidavit
Page 1 of 1
Rev. 11/05/2015