Healogics Vendor Code of Conduct acknowledment

Healogics Vendor Code of Conduct Acknowledgement and Receipt Form

The vendor undersigned below, (“Vendor”) understands they are responsible for ensuring their workforce read and familiarize themselves with the content, requirements and expectations of the Healogics Vendor Code of Conduct and adhere to all of the policies and procedures, whether set forth in the policy or elsewhere. Vendor agrees to abide by the policy guidelines as a condition of doing and continuing to do business with Healogics, Inc.

Vendor understands that a record of this Healogics Vendor Code of Conduct Acknowledgement and Receipt Form document and their signing of it will be stored Healogics Corporate Office.

Vendor also understands that they can locate a printable version of this Healogics Vendor Code of Conduct by accessing the Healogics website.Should Vendor choose not to sign this Healogics Vendor Code of Conduct Acknowledgement and Receipt Form, Vendor will not be allowed to do business with any Healogics managed centers.

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* 1. Vendor information

Company Name

Company Address

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* 2. Vendor Compliance department contact information

Name

Title

Email address

Phone Number

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* 3. Please provide us a description how your products support Healogics' vision and mission:
Our Vision: We are the wound healing expert; driving wound science , healing and prevention forward to help heal more wound and change more lives.

Our Mission: We are committed to advancing wound healing by creating and sharing our wound care expertise everywhere we can, for every patient who would benefit, by the best means available.

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* 4. Will you need to obtain PHI for any reason (specifically, will it require Healogics' staff to provide patient information to the vendor)

Yes (please specify the reason)

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* 5. What is the title of the product that you would like to provide education about?

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* 6. Which Medicare administrative contractors (MACs) cover this product? (check all that apply)

Novitas

Palmetto

FCSO

WPS

CGS

Cahaba

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* 7. Please provide a list of commercial insurance companies that provide coverage for this product (if any)

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* 8. Please provide the states where state Medicaid coverage is available for your product

All states

List specific states where coverage is available

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* 9. Please provide HCPCS code for this product

This is a non billable dressing

HCPCS code

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* 10. By checking this box and typing my name below, I am electronically signing my application.

I have agreed to submit this form by electronic means. By signing this form electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge.
I also certify that:

I understand the questions and statements on this form.
I have read and understand the legal information.
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

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* 11. Vendor Representative's signature

Name

Title

Email address

Phone Number