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.

* 1. Vendor information

* 2. Vendor Compliance department contact information

* 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.

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

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

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

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

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

* 9. Please provide HCPCS code for this product

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

* 11. Vendor Representative's signature