Acknowledgment of Receipt

Healing Rx Acknowledgment of Receipt

Thank you for choosing Healing Rx for your post-surgical wound care needs.

Please review and complete the following acknowledgment form to confirm that you have received your Post Surgical Wound Care Kit as prescribed. This form serves to verify that the equipment has been delivered to you, that you understand its intended use, and that you have received instructions on proper application and care.

Healing RX Receipt Acknowledgement Form

The following Information below has been provided to:

Name Address Patient

Patient Name

First

Last

Welcome Packet
Verbal and Written Instruction
Return Demonstration
Medicare Supplier Standards
Patient/Client Rights and Responsibilities
HIPAA Privacy Notice
Cost of Equipment/Supplies provided
Hours of Operation
Complaint Process
Telephone Number and how to obtain Service
Manufacturer warranty information (if applicable).

Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Disclaimer

By submitting this form, I acknowledge and attest that:

I have received and reviewed the instructions and documentation related to the Wound Care Kit provided by Healing Rx.
I understand the purpose, proper usage, and care of the equipment as outlined in the provided materials.
I agree to contact Healing Rx at 1-888-754-0103 with any questions, concerns, or clarifications regarding the equipment or services received.

I affirm that the information provided is accurate to the best of my knowledge, and I understand that this acknowledgment may be used for documentation and billing purposes in accordance with applicable regulations.