Customer Registration Form

Transcription

1 Customer Registration Form General Company Information Company Main Billing Web Billing A valid address is required for online ordering, account access and real-time order confirmations. Type of Business (check all that apply) Billing Agent Orthopedic Distributor O&P Physical Therapy PCP or GP Tax ID Tax Exempt? Yes No Type of Ownership Corporation Government Partnership Non-Profit Sole Proprietor Duns Years in Business If yes, please send your state resale certificate with application. (see attached example) Primary Contact Information Accounts Payable Contact Information Default Shipping Billing How did you hear about us?

2 Bank References Account number Contact Account number Contact Open Account Credit References Approvals Authorized Signature Date Print Title If you do not have a digital ID please still submit this form electronically by clicking the button below. Also, please send us a copy with your signature to: 6327 W Marginal Way SW, Bldg. 2 Seattle, WA : : For Bellacure Approval Only Submit Electronically Approved by Limit Date Click to Submit by Reset Form

3 Washington State Department of Revenue RESALE CERTIFICATE 1. of Seller SAMPLE 2. of Buyer/Business 3. of Buyer Street City, State Zip 4. Buyer's UBI/Revenue Registration Number 5. Buyer is in the business of 6. Types of items purchased for resale EXEMPT BASED ON SENATE BILL 6599 (or UBI #) GENERIC (VARIETY OF GIFT ITEMS...Orthopedic Supports, etc.) I (the buyer) certify that I am purchasing the items listed on line 6 check (pleaseappropriate box): for resale in the regular course of business without intervening use in the regular course SAMPLE of business, for use as an ingredient or component of a new article of personal tangible property to be produced for sale, as a chemical to be used in processing a new article of tangible property to be produced for sale, or for use as feed, seed, seedlings, fertilizer, or spray materials in my capacity as a farmer. I acknowledge that I am solely responsible for purchasing within the listed categories on line 6. I acknowledge that misuse of the resale privilege claimed use by of this certificate subjects me to a penalty of 50 percent of the tax due, in addition to the tax, interest, and any other penalties imposed by law. Print Signature Effective Date ANY ELECTED OFFICER SAMPLE of Person Authorized to Use Resale Certificate Signature of Person Authorized to Use Resale Certificate through (Not to Exceed 4 Years)

4 Bellacure OA Knee Treatment Device Sizing Chart Size Thigh - 6" (15cm) above knee* Calf - 6" (15cm) below knee* XS 13.5" " (34.5cm cm) 10.0" " (25.5cm cm) S 16.5" " (42.0cm cm) 12.0" " (30.5cm cm) M 19.0" " (48.5cm cm) 14.0" " (35.5cm cm) L 21.5" " (54.5cm cm) 15.0" " (38.0cm cm) XL 24.5" " (62.0cm cm) 16.5" " (42.0cm cm) *Measurement taken from mid patella. If between sizes select the smaller size W Marginal Way SW, Bldg 2 Seattle, WA

5 OA Knee Treatment Device Order Form 6327 West Marginal Way SW, Bldg. 2 Seattle, WA Customer Service Right Medial Compartment Left Medial Compartment part no. size quantity part no. size quantity xsmall xsmall small small medium medium large large xlarge xlarge Right Lateral Compartment Left Lateral Compartment part no. size quantity part no. size quantity xsmall xsmall small small medium medium large large xlarge xlarge Size XS S M L XL Measurment (in)* 6" Above 6" Below * Measurement Taken from mid patella If between sizes select the smaller size. Note: The medial or lateral selection is based on the compartment of the knee being treated for the OA condition. Please visit us online at for ordering in the future or send at orders@bellacure.com. PO Number: Patient : Credit Card on card: Number: Exp: Ship Via: Bill To: Next Day 2nd Day 3 Day Ground Ship To: Company Company City State City State Zip Zip Attention Attention

6 Standard Pricing for the Bellacure OA Knee Treatment Device Part Number Description Price bellacure standard xsmall 1 $ bellacure standard xsmall 2 $ bellacure standard xsmall 3 $ bellacure standard xsmall 4 $ bellacure standard small 1 $ bellacure standard small 2 $ bellacure standard small 3 $ bellacure standard small 4 $ bellacure standard medium 1 $ bellacure standard medium 2 $ bellacure standard medium 3 $ bellacure standard medium 4 $ bellacure standard large 1 $ bellacure standard large 2 $ bellacure standard large 3 $ bellacure standard large 4 $ bellacure standard xlarge 1 $ bellacure standard xlarge 2 $ bellacure standard xlarge 3 $ bellacure standard xlarge 4 $ 459

7 Bellacure L Code Recommendations Bellacure OA Knee Treatment Device Ceiling L1843* KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT, MEDIAL- LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT $ $ L2810* ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PAD $81.76 $61.32 Floor Bellacure OA TD Skin (replacement only) Ceiling Floor L2820* ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE $90.91 $68.18 L2830* ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, ABOVE KNEE $98.35 $73.76 *It is the provider s sole responsibility to verify the accuracy of the HCPCS code(s) used, determine the applicability to each patient, and fulfill the medical necessity and claims documentation requirements. assumes no responsibility or liability for the provider s actions.