Get Replacement Form

Filling out the Replacement Form online is an essential process for facilities participating in the ™ Product Replacement Program. This guide will walk you through each section of the form to ensure a smooth and efficient submission.

Follow the steps to complete the Replacement Form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your online editor.
2. Enter the facility name in the designated field. Ensure all information is correct as this identifies your participation in the program.
3. Fill in the facility address, including street, city, state, and ZIP code. Accuracy in this section is vital for correspondence.
4. Provide the phone number and fax number. These contact details allow for timely communication regarding your application.
5. Input the physician or facility tax ID number. This number is essential for billing and verification purposes.
6. Enter the contact name. This person will be responsible for any correspondence related to the Replacement Program.
7. Review the agreement paragraphs. Ensure you understand the responsibilities and obligations related to the program.
8. Sign the form as the sponsor, entering your title and the date of submission. This signature indicates your authorization to act on behalf of the facility.
9. Finally, save changes to the form and choose to download or print it for submission. You may also share the completed form with the appropriate recipients as specified.

Complete your Replacement Form online today to ensure your facility's participation in the program.