Documente Academic
Documente Profesional
Documente Cultură
CONTENTS
TERMS AND CONDITIONS OF SALE
Baxters Renal Business Unit develops, manufactures and markets a comprehensive selection of
PRODUCTS and services used in the treatment of kidney disease.
Directory of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
General Terms and Conditions of Sale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Warranties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Order/Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Billing/Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Returned Goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APD EQUIPMENT Rental Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
3
4
5-6
7-10
11
12
13-14
P E R I T O N E A L D I A LY S I S
DIANEAL PD Solution, ULTRABAG System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PD1
DIANEAL PD Solution, Single Bag . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EXTRANEAL (icodextrin) PDSolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HOMECHOICE PRO Automated Peritoneal Dialysis System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HOMECHOICE Automated Peritoneal Dialysis System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APD Drain Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APD Miscellaneous Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Disconnect Y-Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Miscellaneous CAPD Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Assist Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Transfer Sets, Catheter Supplies, Disconnect Caps, and Clamps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Trademarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PD2 PD3
PD4
PD5 PD6
PD5 PD6
PD6
PD6
PD7
PD7
PD7
PD8
PDTM
A C U T E D I A LY S I S
Dialysis Solutions for CRRT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AC1
Acute PD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AC1
Trademarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACTM
H E M O D I A LY S I S
HD1
HD2 HD3
HD4
HD5 HD6
HD7
HD8
HDTM
S O F T W A R E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SO1
Trademarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOTM
ANCILLARIES
Sponges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antiseptics/Chemicals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gloves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Blood Pressure Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Permanent Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Miscellaneous Ancillary Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Trademarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AN1
AN1
AN2
AN3
AN3
AN4
AN4
AN4
AN5
ANTM
P R E S C R I P T I O N F O R M S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PF1 PF4
Trademarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PFTM
N U M E R I C A L I N D E X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN1 IN2
DIRECTORY OF SERVICES
HomeCare Services / Order Entry (HOME PATIENTS)
Hours: 7:00 am - 6:00 pm CST
1-800-284-4060
Fax: 1-800-666-8457
Electronic Commerce
http://ecomm.baxter.com
1-877-334-2298
Sales Inquiries
1-888-736-2543
1-800-553-6898
1-800-553-6898
Clinical Support
1-888-736-2543
PRODUCT Surveillance
1-888-736-2543
Hardware Billing
1-800-553-6898
1-888-270-3189
DIRECTACCESS
https://homecareservices.baxter.com/
1-800-284-4060
Pharmacy Services
1-888-736-2543
I.
ALL SALES ARE SUBJECT TO AND EXPRESSLY CONDITIONED UPON THE TERMS AND CONDITIONS
CONTAINED HEREIN, WHICH ARE ACCEPTED BY THE CUSTOMER UPON PLACING OF AN ORDER FOR
PRODUCT WITH BAXTER WHICH ORDER IS CONFIRMED BY BAXTER. NO VARIATION OF THESE TERMS
AND CONDITIONS WILL BE BINDING UPON BAXTER UNLESS AGREED TO IN WRITING AND SIGNED BY
AN AUTHORIZED EMPLOYEE OF BAXTER, OR UNLESS A SEPARATE DIALYSIS PRODUCT PURCHASE
AGREEMENT OR OTHER APPLICABLE SALES DOCUMENT HAS BEEN SIGNED, IN WHICH CASE, SUCH
SALES DOCUMENT SHALL GOVERN IN THE EVENT OF AN EXPRESS CONFLICT WITH THESE TERMS AND
CONDITIONS. THESE TERMS AND CONDITIONS CAN ALSO BE FOUND AT:
http://www.baxter.com/downloads/patients_and_caregivers/therapies/renal/bplpc.pdf
Baxter reserves the right at any time to amend these Terms and Conditions. It is CUSTOMERS responsibility
to review these Terms and Conditions prior to submitting each order. Baxter has no responsibility to notify
CUSTOMER of any changes prior to the effective date of the changes. CUSTOMER shall be deemed to accept
such amended Terms and Conditions by ordering PRODUCT after the date of such amendment.
No Reselling, Transfer or Export
CUSTOMER agrees that PRODUCT purchased from Baxter is not for: a) resale, transfer, barter or trade to any
entity or person, b) use in the further processing, packaging or filling of other drugs, therapies or devices, or
c) export. Neither CUSTOMER nor HOME PATIENT shall transfer any PRODUCT to any other person or entity
except to the person for whom the prescription is written. Any unused PRODUCT, once dispensed or delivered
to HOME PATIENT or CUSTOMER, cannot be transferred to any other patients and must be destroyed in
accordance with applicable state or local regulations or returned to Baxter per the guidelines outlined in the
Returned Goods section of these Terms and Conditions.
Drug and Service State Licensing Requirements
CUSTOMER agrees to maintain all state-mandated licenses and/or permits required to purchase, use, and
dispense Baxter PRODUCT. CUSTOMER shall provide all applicable license and permit information to Baxter
promptly upon request.
Tax, Tax-Exempt Status and Other Fees
CUSTOMER agrees to pay all applicable federal, state, and local taxes (including property taxes); license and
registration fees; and all other fees and costs based on CUSTOMERS lease, rental, purchase, possession or
use of PRODUCT. A CUSTOMER that is exempt from taxation is required to provide valid certification of its
exempt status to Master Data Center of Excellence
(1-877-329-0003; Fax 1-847-948-2540).
No Prohibited Use of PRODUCT
CUSTOMER will not knowingly use, resell, transfer or distribute any PRODUCT directly or indirectly for the
development, production or proliferation of weapons of mass destruction, or missile delivery systems and/or for
any terrorist activities.
II. DEFINITIONS
I I I . WA R R A N T I E S
General Warranty
Baxter warrants that PRODUCT manufactured by Baxter, when used in accordance with the directions on the
labeling, is fit for the purposes and indications described on the labeling. The applicable manufacturer under the
manufacturers warranty will cover PRODUCT not manufactured by Baxter, and Baxter provides no warranty for
PRODUCT not manufactured by Baxter.
The warranty does not apply to any PRODUCT that is misused, abused, neglected, tampered with or damaged
intentionally, by accident, flood, water, fire or other hazard. If PRODUCT is not used in accordance with
manufacturers instructions, PRODUCT warranties are void and of no effect. There are no other express or
implied warranties, including any warranty of merchantability or fitness for a particular purpose. Baxter shall not
be liable for proximate, incidental, or special damages.
All warranties in these Terms and Conditions shall be construed to comply with the warranty Safe Harbor found
at 42 C.F.R. 1001.952(g).
THE WARRANTY IN THIS SECTION SHALL BE IN LIEU OF ANY OTHER WARRANTY EXPRESSED, OR
IMPLIED OR STATUTORY, RESPECTING PRODUCT, AND BAXTER MAKES NO IMPLIED WARRANTY OF
MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. CUSTOMERS SOLE AND EXCLUSIVE
REMEDY IN CONTRACT, TORT OR UNDER ANY OTHER THEORY AGAINST BAXTER WITH RESPECT TO
PRODUCT AND ITS USE SHALL BE THE REPLACEMENT OR REPAIR OF THE PRODUCT AND NO OTHER
REMEDY (INCLUDING, WITHOUT LIMITATION, CONSEQUENTIAL DAMAGES) SHALL BE AVAILABLE
TO CUSTOMER. BAXTER SHALL HAVE NO FURTHER OBLIGATION OR LIABILITY WITH RESPECT TO
PRODUCT, OR ITS SALE, OPERATION AND USE, AND BAXTER NEITHER ASSUMES, NOR AUTHORIZES
THE ASSUMPTION OF, ANY OBLIGATION OR LIABILITY IN CONNECTION WITH SUCH PRODUCT.
EQUIPMENT Warranty
Baxter warrants to CUSTOMER that EQUIPMENT delivered is free from defects in material or workmanship
for the periods specified in the appropriate Operators and Technicians manual (which outlines the complete
warranty), provided EQUIPMENT is used and maintained in accordance with the manufacturers operating
instructions. PARTS installed which have been purchased from vendors other than Baxter shall void all
applicable warranties.
Warranty for EQUIPMENT Service Repair
Service is subject to a thirty (30) day conditional warranty.
I V. O R D E R / D E L I V E R Y
Orders
All orders shall be subject to these Terms and Conditions and shall not be subject to the terms, conditions, or
provisions of any order confirmation, except to the extent that such confirmation specifies quantities.
Baxter will use commercially reasonable efforts to fill orders, but Baxter shall not be liable for non-performance
or delays caused by a FORCE MAJEURE event. CUSTOMER agrees that in any and all such events, Baxter
may allocate PRODUCT among CUSTOMERS without liability or other negative outcome with CUSTOMER.
All orders, with the exception of warranty orders or EQUIPMENT service orders covered under a service
agreement, require a purchase order, supply contract or credit card authorization.
When using a purchase order form, any modification by CUSTOMER regarding pricing, terms of sale or any
other terms or conditions shall not be effective unless accepted in advance and in writing by an authorized
representative of Baxter. Only the list and quantity of PRODUCT and any specific shipping instructions shall be
applicable to said sale.
Selling Unit of Measure
Order quantities must be in the selling unit of measure indicated. Pack factors are noted for ease of ordering.
Prescription Requirement
BAXTER WILL NOT ACCEPT ANY ORDER FOR HOME PATIENT WITHOUT A PRESCRIPTION SIGNED AND
DATED BY A PHYSICIAN, which lists PRODUCT codes, quantities and the allowable refill period, not to exceed
one (1) year. All new APD HOME PATIENT prescriptions must also include either a HomeChoice or HomeChoice
Pro rental. HOMECHOICE devices cannot be shipped until a signed prescription is on file. Prescriptions should
be managed and e-signed through DIRECTACCESS.
CUSTOMER may obtain copies of prescriptions at no charge through DIRECTACCESS. All other manner of
requests shall be subject to a forty dollar ($40.00) processing fee.
Lead Time
Peritoneal dialysis PRODUCT and HD DISPOSABLE orders require a five (5) business day lead time. HD
EQUIPMENT orders require a sixty (60) business day lead time. EQUIPMENT and PART orders requiring
expedited delivery at CUSTOMERS request are subject to an expedited processing and delivery charge quoted
at the time of the order placement. Orders must be placed no later than 12:00 pm local time in the time zone of
CUSTOMERS local Baxter distribution center to be deemed placed on that business day. Orders placed after
12:00 pm local time will be deemed placed on the following business day.
Freight and Distribution
Published prices for DISPOSABLES include regular processing and distribution charges provided the order is
placed five (5) business days prior to the SCHEDULED DELIVERY date. Inside delivery is standard for HOME
PATIENT. Delivery to a Hospital or Center receiving or loading dock is standard while inside delivery is an
additional service and may result in additional charges.
Published prices for EQUIPMENT and PARTS do not include delivery, handling and installation. These charges
will be arranged and billed separately, if applicable.
CUSTOMER is responsible for all freight and distribution charges for all PRODUCT when expedited order
processing and delivery is required, unless specifically provided in these Terms and Conditions.
All shipments are considered contiguous USA only unless otherwise mutually agreed to in writing by
CUSTOMER and Baxter. EQUIPMENT shall be sold FOB Origin. All other PRODUCT shall be sold FOB
Destination; provided that PRODUCT is delivered in accordance with these Terms and Conditions.
Minimum Order Charge
All orders that are less than two hundred fifty dollars ($250.00) will be subject to a charge of forty dollars
($40.00). Exemptions will be permitted only for:
deliveries required to correct Baxter error
new HOME PATIENT orders
SCHEDULED DELIVERY
Hospitals and Centers: Recognizing that Hospitals and Centers have unique delivery and service requirements,
Baxter and CUSTOMER may negotiate a mutually agreeable delivery, which in no event shall be more frequent
than once weekly.
HOME PATIENT: Upon initiation of a new HOME PATIENT account, Baxter will establish a delivery schedule.
HOME PATIENT delivery days shall be set according to this schedule. SCHEDULED DELIVERY will occur
approximately once every four (4) weeks or thirteen (13) times per year.
Delivery frequency and scheduling will be maintained in Baxters transaction management system and will
be used to determine if an order represents a SCHEDULED DELIVERY or OFF-SCHEDULE DELIVERY.
HOME PATIENTS will receive a calendar indicating their ordering days and SCHEDULED DELIVERY days.
Effective July 1, 2011, clinicians requiring a copy of HOME PATIENTS order and delivery schedule must utilize
DIRECTACCESS to obtain a copy. Please contact HomeCare Services at 1-800-284-4060 for details or to setup a DIRECTACCESS account.
HOME PATIENT orders must be placed no later than 12:00 pm local time, five (5) business days prior to the
SCHEDULED DELIVERY date established on the routing calendar. Orders may be placed by telephone or
by fax. Any order received less than five (5) business days prior to the SCHEDULED DELIVERY date will be
considered an EXPEDITED ORDER and will be subject to expediting fees.
Should Baxter initiate a modification in delivery schedules due to route realignment, holiday shipping schedules,
or pre-negotiated accelerated orders or special orders, CUSTOMER shall not incur freight charges for the
shipment of these items.
OFF-SCHEDULE DELIVERY
All OFF-SCHEDULE DELIVERY will be assessed a one hundred fifty dollar ($150.00) service fee. Exemptions will
be permitted only for: a) prescription changes authorized and documented by the physician; b) usage changes
called in by the clinician; c) deliveries required to correct Baxter error; d) domestic travel orders subject to the
Vacation Supply Deliveries section; and e) New HOME PATIENT Orders.
HOME PATIENT RE-DELIVERY
Orders requiring RE-DELIVERY are subject to a charge of seventy-five dollar ($75.00).
EXPEDITED ORDERS
EXPEDITED ORDERS at CUSTOMERS request are subject to an expedited processing charge.
The expedited processing charge for Hospitals or Center orders is one hundred fifty dollars ($150.00) if placed
during normal business hours and two hundred fifty dollars ($250.00) if placed outside of normal business hours
plus actual freight charges.
If an extra delivery is required that can ship ground a fifty dollar ($50.00) extra delivery fee is applied. If order
placed after cut-off but can meet CUSTOMERS SCHEDULED DELIVERY a fifty dollar ($50.00) late fee is
applied.
All Will Call (customer pickup) orders will be assessed a one hundred fifty dollar ($150.00) EXPEDITED ORDER
charge regardless of time of request.
Expedited processing charges for HOME PATIENTS are:
Same
Business Day*
Next
Business Day*
Second
Business Day*
Third
Business Day*
Fourth
Business Day*
$95.00
$65.00
$45.00
$35.00
$25.00
10
V. B I L L I N G / P A Y M E N T
Terms of Sale
All orders are subject to credit approval and acceptance at Baxters home office. Standard payment terms are
net thirty (30) from the date of invoice. Payment terms are in effect as of the date of the order. Payment is made
to the remit to address indicated on the invoice. Credit card payments are subject to approval by Credit and
Collections.
Invoices that are not paid according to the payment terms of each sale shall bear interest at the lesser of
18% per annum or the highest rate allowed by applicable law. Additionally, Baxter reserves the right to require
payment in advance of shipment.
Prices
PRODUCT is priced at the amount indicated for the selling unit of measure ordered. Prices and specifications
are subject to change without notice. All shipments are billed at the price in effect on the date of the order.
PRODUCT is billed upon shipment.
Published PRODUCT prices are exclusive of all taxes.
EQUIPMENT service and separately billable PRODUCT processing and delivery charges are priced as
described in these Terms and Conditions.
Discount Disclosure Statement
CUSTOMER and Baxter intend that all purchases of PRODUCT and services made by CUSTOMER shall be
administered in accordance with the provisions of the federal Anti-Kickback Statute (42, U.S.C. 1320a-7b(b)).
Any discounts and rebates received by CUSTOMER with respect to PRODUCT may be considered discounts
or other reductions in price under the Anti-Kickback Statute, Section 1128B(b)(3)(A) of the Social Security Act
[42 U.S.C. 1320a-7b(b)(3)(A)].
To the extent required by the Anti-Kickback Statute or the Discount Safe Harbor regulations, 42 C.F.R
1001.952(h) et seq., CUSTOMER shall fully and accurately disclose such discounts and other reductions in
price in accordance with the applicable state or federal cost reporting requirements, including, without limitation,
disclosing and accurately reflecting where appropriate, and as appropriate, to the applicable reimbursement
methodology. Baxter will provide CUSTOMER with sales and discount information to allow CUSTOMER to
comply with this Section and the Discount Safe Harbor regulation, including sufficient rebate and pricing
information to enable CUSTOMER to accurately report its actual costs for all purchases of PRODUCT and
services. The total charges for PRODUCT and services purchased by CUSTOMER shall be the contract price
less any such discounts, including rebates.
Credit and Disputes
Only amounts which are disputed in good faith may be withheld from payment pending resolution. Any portion
of an invoice not in dispute must be remitted within the payment terms of each sale. All disputes must be
submitted in writing to Credit and Collections within thirty (30) days from the date of invoice. All disputes or
rights are waived unless the CUSTOMERS complaint has been received by Baxter within such thirty (30) day
period.
11
EQUIPMENT
Purchased EQUIPMENT is not returnable unless shipped in error by Baxter. Leased, rental, trade-in, and/or
evaluation EQUIPMENT may be returned as governed by the terms of this section.
EQUIPMENT returns are at CUSTOMERS expense, and EQUIPMENT must be in the same condition as when
delivered to CUSTOMER, normal wear and tear expected. CUSTOMER shall deliver the EQUIPMENT to such
place or on board such carrier, packed for shipping, as Baxter may specify. CUSTOMER is responsible for
return of EQUIPMENT including all associated charges with the exception of return due to EQUIPMENT shipped
in error by Baxter. CUSTOMER shall give Baxter prior written notice that it is returning EQUIPMENT.
12
V I I . A P D E Q U I P M E N T R E N T A L P R O G R A M
13
Default
The following shall constitute events of default:
CUSTOMER fails to pay monthly rental fee according to the terms stated on the invoice
CUSTOMER fails to perform any of its other obligations under the rental program and such failure continues
for thirty (30) calendar days after Baxter gives CUSTOMER written notice of such failure
A petition in bankruptcy is filed by CUSTOMER or CUSTOMER makes an assignment for the benefit of
creditors, or consents to the appointment of a trustee or receiver, or a trustee or receiver is appointed by
CUSTOMER for any parts of EQUIPMENT or for a substantial part of CUSTOMERS assets without its
consent and is not dismissed within a period of thirty (30) calendar days, or bankruptcy, reorganization, or
insolvency proceedings are instituted against CUSTOMER and are not dismissed within thirty (30) calendar
days thereafter
Upon the happening of any event of CUSTOMER default, Baxter may, at its sole option: a) take immediate
possession of any or all of EQUIPMENT, and, for such purposes, enter upon CUSTOMERS premises or site
where EQUIPMENT is located and remove it, without liability for so doing, or b) require CUSTOMER, at its
expense, to return EQUIPMENT to Baxter as provided in the Returned Goods section.
EQUIPMENT Services and Charges
Global Technical Services provides the scheduling and replacement of APD EQUIPMENT. Replacement of APD
EQUIPMENT will be performed on a next day basis, subject to availability. Expedited replacements are those
requiring same day delivery. Expedited replacements are subject to an additional processing and delivery charge
quoted at the time service is requested.
14
P ER ITO NEAL
DIALYS I S
Na Ca Mg Cl Lactate
DIANEAL Low Calcium PD Solution (mEq/L) 132 2.5 0.5 95 40
DIANEAL PD-2 PD Solution (mEq/L)
132 3.5 0.5 96 40
DIANEAL PD-2 and Low Calcium peritoneal dialysis solutions in
ULTRABAG containers are indicated for use in chronic renal
failure patients being maintained on continuous ambulatory peritoneal
dialysis when nondialytic medical therapy is judged to be inadequate.
Important Risk Information for DIANEAL Solutions
n Not for Intravenous Injection.
n Use aseptic technique. Contamination of connector may result in
peritonitis.
n Adverse reactions to peritoneal dialysis include mechanical and
solution related problems as well as the results of
contamination of equipment.
n Solution-related adverse reactions may include peritonitis,
electrolyte and fluid imbalances, hypovolemia, hypervolemia,
hypotension, hypertension, disequilibrium syndrome, allergic
symptoms, and muscle cramping.
n Please see enclosed package inserts for DIANEAL solution full
prescribing information.
Dextrose
Pack Factor
Price/Case
5B9765P
1.5%
1500
5B9775P
2.5%
1500
5B9795P
4.25%
1500
5B9766
1.5%
2000
5B9776
2.5%
2000
5B9796 4.25% 2000
5B9768P
1.5%
2500
5B9778P
2.5%
2500
5B9798P
4.25%
2500
5B9757
1.5%
3000
5B9758 2.5% 3000
5B9759
4.25%
3000
2000
2000
2000
2000
2000
2000
3000
3000
3000
5000
5000
5000
8/case
8/case
8/case
6/case
6/case
6/case
5/case
5/case
5/case
4/case
4/case
4/case
$272.57
$280.10
$282.22
$191.07
$213.18
$215.13
$176.73
$181.74
$185.64
$156.37
$159.84
$164.72
D I A N E A L P D - 2 P D S o l u t i o n
5B9866
1.5%
2000
5B9876
2.5%
2000
5B9896 4.25% 2000
5B9868P 1.5% 2500
5B9878P
2.5%
2500
5B9898P 4.25% 2500
5B9857 1.5% 3000
5B9858 2.5% 3000
5B9859 4.25% 3000
2000
2000
2000
3000
3000
3000
5000
5000
5000
6/case
6/case
6/case
5/case
5/case
5/case
4/case
4/case
4/case
$191.07
$213.18
$215.13
$176.73
$181.74
$185.64
$156.37
$159.84
$164.72
PD1
P ER ITO NEAL
DIALYS I S
Na Ca Mg Cl Lactate
DIANEAL Low Calcium PD Solution (mEq/L) 132 2.5 0.5 95 40
DIANEAL PD-2 PD Solution (mEq/L)
132 3.5 0.5 96 40
n
n
Dextrose
3000
3000
3000
3000
3000
3000
6000
6000
6000
6000
6000
6000
Pack Factor
Price/Case
6/case
6/case
6/case
4/case
4/case
4/case
2/case
2/case
2/case
2/case
2/case
2/case
$120.90
$144.92
$146.73
$138.36
$140.30
$143.31
$74.15
$75.88
$77.72
$88.61
$90.54
$93.04
Dextrose
PD2
1000
1000
1000
3000
3000
3000
3000
3000
3000
6000
6000
6000
6000
6000
6000
Pack Factor
Price/Case
12/case
12/case
12/case
6/case
6/case
6/case
4/case
4/case
4/case
2/case
2/case
2/case
2/case
2/case
2/case
$350.18
$365.35
$376.59
$121.75
$145.60
$148.04
$136.97
$139.92
$143.78
$74.15
$75.87
$77.54
$87.93
$90.24
$92.56
P ER ITO NEAL
DIALYS I S
Icodextrin
7.5%
7.5%
Pack Factor
Price/Case
2000
2500
2000
3000
6/case
5/case
per contract
per contract
Icodextrin
7.5%
7.5%
Pack Factor
Price/Case
2000
2500
2000
3000
6/case
5/case
per contract
per contract
PD3
P ER ITO NEAL
DIALYS I S
SYSTE M S
HOMECHOICE System
Description
Pack Factor
Price
Devices
5C4471
5C8310
1/each
1/each
$17,719.67
$20,251.06
L u e r D i s p o s a b l e S e t s
R5C4479C
L5C4531
N5C8305C
30/case
30/case
30/case
$966.63
$1,303.78
$2,786.84
n
Integrated APD Set has 3 supply lines, and 22 patient and drain lines.
n
Low Recirculation Volume APD Set has in-line medication port, a shrouded patient connector, and a smaller internal
diameter and shorter patient line length. Recirculation volume 17mL.
Rx Only. For safe and proper use refer to Operators Manual.
PD4
P ER ITO NEAL
DIALYS I S
SYSTE M S
Description
Pack Factor
Price
Data Cards
R5C4522
4994000449
C a r r y i n g C a s e s
5C4406
5C8346
Carrying Case
Hard Carrying Case with Wheels
1/each
1/each
$153.49
$453.51
E x t e n s i o n L i n e s
5C4480C
30/case
$246.60
30/case
30/case
6/case
30/case
$303.44
$170.97
$58.01
$219.79
48/case
30/case
15/case
15/case
1/each
$610.13
$417.61
$228.70
$268.83
$48.18
PD5
P ER ITO NEAL
DIALYS I S
SYSTE M S
CAPD
Product
Description
Pack Factor
Price
D i s c o n n e c t Y- S e t s
5C4366P
ULTRASET Disposable Disconnect Y-Set (Spike)
L5C4366
ULTRASET Disposable Disconnect Y-Set (Luer)
M i s c e l l a n e o u s C A P D S u p p l i e s
60/case
30/case
$552.61
$315.07
5C4530
5C4190
48/case
1/each
$586.86
$109.81
Assist Devices
CXD II Compact Exchange Device for APD Patients
Product
Description
Device
5C4275
1/each
$660.12
1/each
$86.10
C a r r y i n g C a s e
5C4942
Product
Description
5C4505
PD6
1/each
$200.91
PERITONEAL DIALYSIS
Product
PATIENT
Description
CONNECTOLOGY
Pack Factor
Price/Case
Transfer Sets
5C4442 Extended Life EASY-LOCK Transfer Set (6)
6/case
$377.56
5C4449 MINICAP Extended Life PD Transfer Set (6) with Roller Clamp 6/case
$377.56
5C4482 MINICAP Extended Life PD Transfer Set (6) with Twist Clamp 6/case
$344.00
5C4483 MINICAP Extended Life PD Transfer Set Extra Short (4)
6/case
$360.39
with Twist Clamp
5C4160 Transfer Set with Spike Connector (48)
12/case
$248.57
ULTRACLAMP Clamp
T RA DEMAR KS
For peritoneal dialysis products listed on pages PD1-PD7
The following is a listing of trademarks of Baxter International Inc:
Ambu-Flex
Baxter
Dianeal
Easy-Lock
Extraneal
FlexiCap
HomeChoice
HomeChoice PRO
Immobilizer
MiniCap
QuietCoil
UltraBag
UltraClamp
UltraSet
PDTM
A CUTE
DIALYSIS
2/case
$80.12
Acute PD
Catheter Supplies
Product
Description
2C7565
Pack Factor
Price/Case
48/case
$529.92
15/case
$228.70
Disposable Sets
5C4446
AC1
T RA DEMAR KS
For acute dialysis products listed on page AC1
The following is a listing of trademarks of Baxter International Inc:
Accusol
Baxter
Buretrol
InterLink
The following is a listing of trademarks of Minntech Corporation:
Minifilter
Renaflo
ACTM
H EMO DI ALYSIS
Description
Pack Factor
HCT1000B
HD1
288/case
Price
$1,817.96
H EMO DI ALYSIS
D IA L YZE R S
SINGLE-USE
X E N I U M XPH Dialyzers, High Flux, Synthetic
Product
Description
H25601A
H25602A
H25603A
H25604A
H25605A
H25606A
24/case
24/case
24/case
24/case
24/case
24/case
$748.22
$793.56
$888.46
$943.00
$1,006.96
$1,085.00
Description
5M6400
5M6401
5M6402
5M6403
5M6404
5M6405
24/case
24/case
24/case
24/case
24/case
24/case
$748.22
$793.56
$888.46
$943.00
$1,006.96
$1,085.00
Product
Description
5M2119
5M2120
5M2121
5M2132
Pack Factor
Price/Case
24/case
24/case
24/case
24/case
$1,365.61
$1,405.23
$1,450.22
$1,485.52
Product
Description
5M2591
5M2592
5M2593
5M2594
5M2595
5M2596
Pack Factor
Price/Case
24/case
24/case
24/case
24/case
24/case
24/case
$1,084.95
$1,200.89
$1,245.92
$1,287.95
$1,360.92
$1,466.75
H E M O DIALYSIS
D IA L YZE R S
SINGLE-USE
C A Cellulose Acetate Hollow Fiber Dialyzers, Conventional
Product
Description
Pack Factor
5M1729
5M1730
24/case
24/case
Price/Case
$834.39
$834.39
REUSE
C T Cellulose Triacetate Hollow Fiber Dialyzers, High Flux
Product
Description
5M1542
5M1546
CT 110G dialyzer
CT 190G dialyzer
Pack Factor
Price/Case
24/case
24/case
$1,395.68
$1,504.45
Product
Description
5M2731
5M2732
5M2733
5M2734
5M2735
5M2736
CA-HP 90 dialyzer
CA-HP 110 dialyzer
CA-HP 130 dialyzer
CA-HP 150 dialyzer
CA-HP 170 dialyzer
CA-HP 210 dialyzer
HD3
Pack Factor
Price/Case
24/case
24/case
24/case
24/case
24/case
24/case
$1,084.95
$1,200.89
$1,245.92
$1,287.95
$1,360.92
$1,466.75
H EMO DI ALYSIS
B L OOD
TU B I N G
S E TS
Description
*5M9634
8 mm pump segment, pre-pump pillow, post-pump arterial chamber
*A201V801 1/4 pump segment, pre-pump arterial chamber
*A203V801 8 mm pump segment, pre-pump arterial chamber
*A204V801 8 mm pump segment, post-pump arterial chamber
A209YV803 8 mm pump segment, pre-pump arterial chamber, Y-port saline set
A210V803 8 mm pump segment, post-pump arterial chamber
A217YV806 8 mm pump segment, post-pump arterial chamber, Y-port saline set
*These tubing sets are compatible with selected Baxter Hemodialysis Instruments.
24/case
24/case
24/case
24/case
24/case
24/case
24/case
$207.77
$207.77
$207.77
$207.77
$207.77
$207.77
$207.77
Please refer to the Recommended Blood Tubing Set Matrix for Baxter Hemodialysis Instruments. Baxter cannot
recommend using sets outside the sets listed in the matrix. Please also refer to the Blood Tubing Set-up Guide for proper
set-up for each recommended blood tubing set. For a copy of either the Blood Tubing Set Matrix or the Blood Tubing
Set-up Guide please contact Renal Technical Support at 1-800-553-6898, Select 1 for English, Prompt 4, Option 1.
HD4
H EMO DI ALYSIS
F ISTU L A
N E E D L E S
Nipros SAFETOUCH II Safety Fistula Needle, Single Needle Set with Back-Eye
Product
Description
FS1425BC
FS1525BC
FS1525BCR
FS1532BC
FS1625BC
FS1625BCR
FS163230BC
FS1725BC
FS173230BC
Nipros SAFETOUCH II Safety Fistula Needle, Twin Pack Needle Set, Arterial Needle with
Back-Eye, Venous Needle without Back-Eye
Product
Description
Pack Factor
Price/Case
FS142530TP
FS142530TPR
FS152530TP
FS152530TPR
FS162530TP
FS162530TPR
FS172530TP
FS172530TPR
250 pair/case
250 pair/case
250 pair/case
250 pair/case
250 pair/case
250 pair/case
250 pair/case
250 pair/case
$876.52
$904.65
$876.52
$904.65
$876.52
$904.65
$876.52
$904.65
Product
Description
Pack Factor
Price/Case
FD152530BC
50/case
$93.06
Nipros TULIP Safety Fistula Needle, Single Needle Set with Back-Eye
Product
Description
Pack Factor
Price/Case
HD5
H EMO DI ALYSIS
F ISTU L A
N E E D L E S
Nipros TULIP Safety Fistula Needle, Twin Pack Needle Set, Arterial Needle with Back-Eye,
Venous Needle without Back-Eye
Product
FT142530TP
FT152530TP
FT162530TP
FT172530TP
Description
TULIP 14G x 1 Fixed Hub Twin Pack
TULIP 15G x 1 Fixed Hub Twin Pack
TULIP 16G x 1 Fixed Hub Twin Pack
TULIP 17G x 1 Fixed Hub Twin Pack
HD6
Pack Factor
Price/Case
$438.25
$438.25
$438.25
$438.25
HEMODIALYSIS
DISPOSABLE
SUPPLIES
Description
Pack Factor
Price/Case
$541.06
$557.29
$546.47
Description
TPSURE1
PS01
Transducer Protector
Priming Set
Pack Factor
1000/case
200/case
Price/Case
$1,113.95
$200.19
Intravenous Injections In VIAFLEX Plastic Containers (Saline)
Sodium Chloride Injections
Product
Description
2B1321
2B1322Q
2B1323Q
2B1324X
Pack Factor
150
250
500
1000
36/case
36/case
24/case
14/case
Price/Case
$193.32
$193.32
$128.88
$81.34
Description
2F7112
2F7115
2F7122
2F7124
2F7125
HD7
Pack Factor
24/case
9/case
24/case
12/case
9/case
Price/Case
$146.64
$87.93
$153.12
$89.88
$91.80
H EMO DI ALYSIS
C O N C E N TR A TE S
1.00
2.00
1.00
2.00
0.00
2.00
3.00
0.00
3.00
2.50
3.50
3.50
3.00
2.50
2.50
3.00
0.00
2.50
1.00 105.50
1.00 106.50
1.00 105.50
1.00 110.00
1.00 104.50
1.00 105.50
1.00 107.00
1.00 101.00
0.75 106.25
4.0
4.0
4.0
4.5
4.0
4.0
4.0
4.0
4.0
200
200
200
200
200
200
200
200
200
35.0
35.0
35.0
35.5
35.0
35.0
35.0
35.0
35.0
4/case
4/case
4/case
4/case
4/case
4/case
4/case
4/case
4/case
$45.45
$45.45
$45.45
$45.45
$45.45
$45.45
$45.45
$45.45
$45.45
0.00
2.00
1.00
2.00
1.00
3.00
2.25
2.50
3.00
3.00
2.25
3.00
0.75 103.00
0.75 105.25
0.75 104.75
0.75 105.75
0.75 104.00
0.75 106.75
5.0
4.0
4.0
4.0
5.0
4.0
200
200
200
200
200
200
32.0
33.0
33.0
33.0
32.0
33.0
4/case
4/case
4/case
4/case
4/case
4/case
$49.78
$49.78
$49.78
$49.78
$49.78
$49.78
Description
Pack Factor
Price/Case
5M7828
5M7829
20 packets/case $104.97
4/case
$58.43
COBE (B-Side)
Product
Description
Pack Factor
5M7905
5M7906
Bicarbonate Concentrate Powder for COBE Proportioning Systems (2.1 gal: 8 liters)
Liquid Bicarbonate Concentrate for use with COBE (45x) Proportioning Systems
(1 gal; 3.78 liters)
20 packets/case $104.97
4/case
$58.43
HD8
Price/Case
T RA DEMAR KS
For hemodialysis products listed on pages HD1-HD8
The following is a listing of trademarks of Baxter International Inc:
Baxter
CA
CA-HP
CT
Dicea
Exeltra
Hemavision
Viaflex
Xenium
The following is a listing of trademarks of VascA, Inc:
LifeSite
The following is a listing of trademarks of Cardian NBCT, Inc:
COBE
The following is a listing of trademarks of Nipro Corporation:
Dose-Saver
SafeTouch II
Tulip
HDTM
S O FTW AR E
Renal Software Suite (for use with HOMECHOICEPRO Automated PD System)
Product
Description
Pack Factor
5M5730
5M5730U
1/each
1/each
1/each
SO1
1/each
T RA DEMAR KS
For software products listed on page SO1
The following is a listing of trademarks of Baxter International Inc:
Baxter
HomeChoice PRO
RenalSoft
SOTM
A NC ILLAR IES
Sponges
Gauze Sponge
Product
5K7458P
5K7407P
5K7424P
5K7505P
5K7416P
5K7426P
5K7425P
5K7567P
5K7559P
5K7589P
5K7428P
5K7543P
5K7427P
5K7525P
5K7430P
IV Sponge
Description
Pack Factor Price/Box
SORB-IT IV Sponge (split) 2 x 2 6-ply Sterile
35/box
$17.48
EXCILON Drain Sponge (split) 4 x 4 6-ply Sterile
25/box
$38.71
CURITY Gauze Sponge 2 x 2 8-ply Sterile
50/box
$9.23
CURITY Gauze Sponge 4 x 4 8-ply Sterile
25/box
$10.41
CURITY Gauze Sponge 4 x 4 12-ply Sterile
25/box
$11.45
CURITY Gauze Sponge 2 x 2 12-ply Non-Sterile
200/box
$11.77
CURITY Gauze Pad 2 x 2 12-ply Sterile
100/box
$28.36
VERSALON All Purpose Sponge 2 x 2 4-ply Sterile 25/box
$4.44
VERSALON All Purpose Sponge 3 x 3 4-ply Sterile 25/box
$8.22
VERSALON All Purpose Sponge 4 x 4 4-ply Sterile 25/box
$10.75
CURITY Cover Sponge 4 x 3 Sterile
25/box
$11.93
CURITY Cover Sponge 4 x 4 Sterile
25/box
$13.35
CURITY Cover Sponge 3 x 3 Non-Sterile
100/box
$10.35
CURITY Cover Sponge 4 x 3 Non-Sterile
100/box
$14.35
CURITY Cover Sponge 4 x 4 Non-Sterile
100/box
$19.79
Dressings
Product
5K7401P
5K7479P
5K7538P
5K7548P
5K7568P
5K7532P
5K7588P
5K7522P
5K7523P
5K7459P
5K7580P
5K7579P
5K7578P
Description
Pack Factor Price/Box
COVERLET Adhesive Bandage, Flexible 1 x 3
100/box
$24.49
BIOPATCH Antimicrobial Dressing - 1 disk w/7.0 mm center hole
10/box
$180.73
PRIMAPORE Adhesive Dressing 4 x 31/8 Sterile
20/box
$47.53
PRIMAPORE Adhesive Dressing 6 x 31/8 Sterile
20/box
$51.88
PRIMAPORE Adhesive Dressing 8 x 4 Sterile
20/box
$66.36
TELFA Adhesive Island Dressing 2 x 31/2 Sterile
50/box
$21.70
TELFA Adhesive Island Dressing 4 x 5 Sterile
25/box
$83.00
VIASORB Wound Dressing 2 x 3 Sterile
20/box
$109.27
VIASORB Wound Dressing 4 x 6 Sterile
20/box
$151.23
1
3
OPSITE Post Op Dressing 6 /8 x 3 /8 Sterile
20/box
$87.89
TEGADERM Transparent Dressing 23/8 x 23/4 Sterile
100/box
$124.97
TEGADERM Transparent Dressing 4 x 43/4 Sterile
50/box
$195.31
TEGADERM Transparent Dressing 6 x 8 Sterile
10/box
$88.98
AN1
A NC ILLAR IES
Tape
Cloth Tape
Product
5K7624
5K7630
5K7639
5K7615
5K7617
5K7660
5K7667
5K7619
5K7627
Description
Cloth Tape 1 x 10 yds
Cloth Tape 2 x 10 yds
Soft Cloth Tape 2 x 10 yds
Paper Tape 1 x 10 yds
Paper Tape 2 x 10 yds
Paper Tape 1 x 10 yds w/Dispenser
Paper Tape 2 x 10 yds w/Dispenser
Plastic Tape 1 x 10 yds
Plastic Tape 2 x 10 yds
Paper Tape
Plastic Tape
AN2
Pack Factor
1/ea
1/ea
1/ea
1/ea
1/ea
1/ea
1/ea
1/ea
1/ea
Price/Box
$2.24
$4.93
$20.91
$1.90
$3.63
$1.87
$3.77
$3.07
$6.97
A NC ILL AR IES
Antiseptics/Chemicals
Surgical Scrub
Product
Description
Pack Factor
5K4075
5K4227
5K4070
5K4066
5K4054P
5K4005
5K4027
5K4001
5K4172P
5K4012P
5K4013P
5K8148P
5K8058P
5K4033P
5K4265P
5K4291P
5K4226
5K4225P
5K4285
5K4286P
5K4077
Price
1 ea
$22.27
1 ea
$11.17
1 ea
$9.36
1 ea
$30.96
25/box
$96.43
1 ea
$20.53
1 ea
$25.52
1 ea
$3.69
200/box
$7.97
100/box $22.44
25/box
$22.68
50/box
$25.06
100/box
$29.78
50/box
$77.58
1 ea
$156.18
50/box
$63.58
1 ea
$47.43
100/bottle
$71.41
1 ea
$86.99
100/box
$88.70
1 ea
$53.62
Gloves
Product
Description
Pack Factor
5K7777P
5K7778P
5K7779P
AN3
100/box
100/box
100/box
Price/Box
$26.79
$26.79
$26.79
A NC ILLAR IES
Blood Pressure Units
Product
Description
5K3966
5K3967
5K3968
Digital Auto Inflate Blood Pressure Unit w/medium cuff (arm girth 9.4 - 14.2)
Digital Auto Inflate Blood Pressure Unit w/small cuff (arm girth 6.3 - 9.4)
Digital Auto Inflate Blood Pressure Unit w/large cuff (arm girth 14.2 - 17.7)
Product
Description
5K3517
5K3545
5K3575
5K3582
5K3585
Pack Factor
Price/Each
1/each
1/each
1/each
$186.76
$180.36
$203.00
Pack Factor
Price/Each
1/each
1/each
1/each
1/each
1/each
$559.58
$333.94
$116.10
$21.08
$20.65
Pack Factor
Price/Each
Scales
Permanent Equipment
Product
Description
5K3961
5Q3810
5K3572
5K3826
5K8100
AN4
1/each
1/each
1/each
1/each
1/each
$83.61
$117.40
$13.86
$408.91
$1,209.32
A NC ILLAR IES
Miscellaneous Ancillary Supplies
Product
Description
5K7444P
5K7402P
5K4500
5K3739
5K7406P
5K8123P
5K8070P
5K8032P
5K8065P
Pack Factor
Price/Each
100/box
50/box
1 ea
1 ea
100/box
50/box
50/box
50/box
250/box
$20.87
$48.73
$5.54
$6.04
$22.79
$8.03
$15.42
$27.58
$78.49
Face Mask
AN5
T RA DEMAR KS
For ancillary products listed on pages AN1-AN5
The following is a listing of trademarks of Alcavis HDC, LLC:
Alcavis
Exsept Plus
Manugel
The following is a listing of trademarks of Bayer Healthcare LLC:
Hemastix
The following is a listing of trademarks of BSN Medical gmbh Corporation:
Coverlet
The following is a trademark of Covidien AG:
Beta-Cap
Viasorb
The following is a listing of trademarks of E-Med Corporation:
IV Strip
The following is a trademark of E.R. Squibb & Sons, LLC:
Shur-Clens
The following is a listing of trademarks of Johnson & Johnson Corporation:
BioPatch
The following is a listing of trademarks of Minntech Corporation:
Actril
Minncare
The following is a trademark of Nitto Denko Corp.:
Xtrata
The following is a listing of trademarks of Purdue Frederick Company:
Betasept
The following is a listing of trademarks of Serim Research Corporation:
Serim
The following is a listing of trademarks of Smith & Nephew Medical Limited:
Opsite
Primapore
Skin-Prep
The following is a trademark of Steris Inc.:
Cal-Stat
The following is a listing of trademarks of Tyco Healthcare Group LP
Curity
Excilon
Sorb-It
Telfa
Versalon
The following is a trademark of 3M Company:
Tegaderm
ANTM
Non-Diabetic
Zip
/
State
DOB
/
Zip
State
Phone
Phone
LowCal
L
L
L
L
L
L
L
L
30
30
30
30
5C4480C
5C4464P
Physician:
Signature (Substitution Permitted)
1
1
1
DIANEAL PD Solution:
L5B
1.5%
L5B
2.5%
L5B
4.25%
5B
5B
5B
5B
5B
PD2
(Dispense as Written)
5K8070P
5K8123P
50
50
1 roll
1 roll
1 roll
Paper Tape 1
Plastic Tape 1
Cloth Tape 1
5K7615
5K7619
5K7624
12
12
25
35
50
5C4527
5C4957
60
30
Ancillaries:
5K7416P Gauze Sponge 4 x 4 12-ply
5K7458P IV Sponge 2 x 2 6-ply
5K7424P Gauze Sponge 2 x 2 8-ply
5C4466P
5C4456
Date
State
PO#
Zip
Phone
Max
Qty
Description
Ord
Qty
1
1
1
1
Pack
Factor
Max
Qty
To
To
Clinic Patient
Ord
Qty
PF1
USE AS DIRECTED
VALKITA
VALKITAL
VALKITC
VALKITCL
VALKITP
5K3961
5Q3810
5K3582
5K3966
5K3575
5K3572
valkits/Permanent Equipment:
Ancillaries (cont.):
5K4070
Antimicrobial Soap 16oz.
5K4075
mANUgEL 85 Antiseptic
5K4066
ExSEPT PLUS Antiseptic
5K4005
ALcAvIS 50 (500ml)
Product
Code
Ord
Qty
Clinic/Hospital
Address
City
Contact
This ESRD patient has been trained in Home Peritoneal Dialysis and will require the supplies listed below.
Product
% Dextrose
Fill Vol Pack Ord Max
Product
Description
Pack
Code
Factor Qty
Qty
Code
Factor
Diabetic type:
Patient Name
Alternate Contact
Delivery Address
City
Mailing Address (if different)
City
Gender:
Male
Female
Non-Diabetic
Zip
/
State
DOB
/
Zip
State
Phone
Phone
LowCal
L
L
L
L
L
L
Disconnect Y-Set
Immobile (Velcro)
ImmOBILIzER
L5C4366
5C4319
5C4381
Physician:
Signature (Substitution Permitted)
12
12
5C4527
5C4957
30
30
30
60
Disposables:
5C4466P mINIcAP Disconnect Cap
5K8070P
5K8123P
Date
(Dispense as Written)
1 roll
1 roll
1 roll
Paper Tape 1
Plastic Tape 1
Cloth Tape 1
5K7615
5K7619
5K7624
1
1
1
1
50
50
25
35
50
Ancillaries:
5K7416P Gauze Sponge 4 x 4 12-ply
5K7458P IV Sponge 2 x 2 6-ply
5K7424P Gauze Sponge 2 x 2 8-ply
5K4070
5K4075
5K4066
5K4005
State
PO#
Zip
Phone
Max
Qty
USE AS DIRECTED
Ord
Qty
Pack
Factor
Max
Qty
To
To
Clinic Patient
Ord
Qty
PF2
valkits/Permanent Equipment:
No IV Pole, Reg BP Cuff
VALKITA
VALKITAL No IV Pole, Lg BP Cuff
w/IV Pole, Reg BP Cuff
VALKITC
VALKITCL w/IV Pole, Lg BP Cuff
No Scale, Sm BP Cuff
VALKITP
5K3961
Heating Pad, King Size
5Q3810
IV Pole
5K3582
Scale Spring
5K3966
BP Unit, Digital (Medium Cuff)
5K3575
Scale, Digital
5K3572
Thermometer, Digital
Product
Description
Code
Additional Items:
Ord
Qty
Clinic/Hospital
Address
City
Contact
This ESRD patient has been trained in Home Peritoneal Dialysis and will require the supplies listed below.
Product
% Dextrose
Fill Vol Pack Ord Max Product
Description
Pack
Code
Factor Qty
Qty
Code
Factor
Diabetic type:
Patient Name
Alternate Contact
Delivery Address
City
Mailing Address (if different)
City
Gender:
Male
Female
Non-Diabetic
Dialyzer
5M
50
100
1
1
5K4077
5K4226
Physician:
Signature (Substitution Permitted)
1000
Fistula___G x ____
Acid Concentrate
Bicarbonate Concentrate, Liquid
Bicarbonate Concentrate,
Powder
5M
5M
5M
Pack
Factor
14
Ord
Qty
Product Description
Code
2B1324X 0.9% Saline Inj., USP 1000mL
Diabetic type:
Patient Name
Alternate Contact
Delivery Address
City
Mailing Address (if different)
City
Gender:
Male
Female
Max
Qty
1 roll
1 roll
1 roll
5K7615
5K7619
5K7624
Date
5K4001
5K4172P
5K4012P
5K4013P
5K4070
5K4075
(Dispense as Written)
1
200
100
25
1
1
50
50
25
35
Pack
Factor
Paper Tape 1
Plastic Tape 1
Cloth Tape 1
State
PO#
Zip
Phone
Max
Qty
Gloves
5K77
USE AS DIRECTED
1
1
1
1
100
100
Pack Ord
Factor Qty
Max
Qty
PF3
Permanent Equipment:
5K3966
BP Unit, Digital (Medium Cuff)
5K3575
Scale, Digital
5K3739
Forceps 4 1/4
5K3826
Dialysis Bath Conductivity Meter
Additional Items:
5K7444P
Product
Description
Code
Ancillaries (cont.):
Ord
Qty
Clinic/Hospital
Address
City
Contact
Product Description
Code
Ancillaries:
5K7416P Gauze Sponge 4 x 4 12-ply
5K7458P IV Sponge 2 x 2 6-ply
Zip
/
State
DOB
/
Zip
State
Phone
Phone
HD Prescription Form
PF4
New Patient
Reactivated Patient
Therapy Change
Transfer Patient
You may be able to avoid this fax by using the DirectAccess online tool. The DirectAccess online tool is the preferred way for you to do business
with Baxter. With the DirectAccess online tool, you can quickly and easily set up or modify patient prescriptions and forward them to doctors for their
eSignature. Work smarter with the DirectAccess online tool.
To learn how, visit the landing page at www.baxter.com/homecareservices to sign up, download a user guide, attend a webinar training, or practice on
your own using our new training environment, the Playground.
Patient Name
Attending Physician
Clinic Contact
HomeChoice Cycler
HomeChoice PRO Cycler
Carrying Case
Clinic Phone#
Clinic Name
To Patient
To Clinic (Address Below)
Billing Information
THERAPY
APD
CAPD
Home HD
56 Days
84 Days
DELIVERY CYCLE
28 Days
To Clinic
PRODUCT CODE
TO CLINIC TO PATIENT
COMMENTS
T RA DEMAR KS
For prescription forms listed on pages PF1-PF4
The following is a listing of trademarks of Baxter International Inc.:
Baxter
Dianeal
DirectAccess
Extraneal
HomeChoice
HomeChoice PRO
MiniCap
UltraBag
UltraClamp
The following is a listing of trademarks of Minntech Corporation:
Actril
The following is a listing of trademarks of Bayer Healthcare LLC:
Hemastix
The following is a listing of trademarks of Alcavis HDC,LLC:
Manugel
PFTM
N UM ER I CAL
INDEX
Code Page
Code Page
Code Page
Code Page
2B1321 HD7
5C4137 PD7
5K3739 AN5
5K7505P AN1
2B1322Q HD7
5C4145P PD5
5K3826 AN4
5K7522P AN1
2B1323Q HD7
5C4160 PD7
5K3961 AN4
5K7523P AN1
2B1324X HD7
5C4169 PD7
5K3966 AN4
5K7525P AN1
2C7565 AC1
5C4190 PD6
5K3967 AN4
5K7532P AN1
2F7112 HD7
5C4212P PD7
5K3968 AN4
5K7538P AN1
2F7115 HD7
5C4213P PD7
5K4001 AN3
5K7543P AN1
2F7122 HD7
5C4215P PD7
5K4005 AN3
5K7548P AN1
2F7124 HD7
5C4275 PD6
5K4012P AN3
5K7559P AN1
2F7125 HD7
5C4319 PD7
5K4013P AN3
5K7567P AN1
5B4984 PD3
5C4366P PD6
5K4027 AN3
5K7568P AN1
5B4986 PD3
5C4381 PD7
5K4033P AN3
5K7578P AN1
5B7860 AC1
5C4406 PD5
5K4054P AN3
5K7579P AN1
5B9248 AC1
5C4413 PD7
5K4066 AN3
5K7580P AN1
5B9249 AC1
5C4426 PD5
5K4070 AN3
5K7588P AN1
5B9250 AC1
5C4442 PD7
5K4075 AN3
5K7589P AN1
5B9251 AC1
5C4446
PD5, AC1
5K4077 AN3
5K7615 AN2
5B9252 AC1
5C4449 PD7
5K4172P AN3
5K7617 AN2
5B9757 PD1
5C4456 PD7
5K4225P AN3
5K7619 AN2
5B9758 PD1
5C4462 PD5
5K4226 AN3
5K7624 AN2
5B9759 PD1
5C4464P PD5
5K4227 AN3
5K7627 AN2
5B9765P PD1
5C4471 PD4
5K4265P AN3
5K7630 AN2
5B9766 PD1
5C4476 PD5
5K4285 AN3
5K7639 AN2
5B9768P PD1
5C4480C PD5
5K4286P AN3
5K7660 AN2
5B9775P PD1
5C4482 PD7
5K4291P AN3
5K7667 AN2
5B9776 PD1
5C4483 PD7
5K4500 AN3
5K7777P AN3
5B9778P PD1
5C4505 PD6
5K7401P AN1
5K7778P AN3
5B9795P PD1
5C4512 PD5
5K7402P AN5
5K7779P AN3
5B9796 PD1
5C4527 PD7
5K7406P AN5
5K8032P AN5
5B9798P PD1
5C4530 PD6
5K7407P AN1
5K8058P AN3
5B9857 PD1
5C4942 PD6
5K7416P AN1
5K8065P AN5
5B9858 PD1
5C4957 PD7
5K7424P AN1
5K8070P AN5
5B9859 PD1
5C4971 PD5
5K7425P AN1
5K8100 AN4
5B9866 PD1
5C8310 PD4
5K7426P AN1
5K8123P AN5
5B9868P PD1
5C8346 PD5
5K7427P AN1
5K8148P AN3
5B9876 PD1
5K3517 AN4
5K7428P AN1
5M1542 HD3
5B9878P PD1
5K3545 AN4
5K7430P AN1
5M1546 HD3
5B9896 PD1
5K3572 AN4
5K7444P AN5
5M1729 HD3
5B9898P PD1
5K3575 AN4
5K7458P AN1
5M1730 HD3
5C4129 PD7
5K3582 AN4
5K7459P AN1
5M2119 HD2
5C4136 PD7
5K3585 AN4
5K7479P AN1
5M2120 HD2
IN1
N UM ER I CAL
INDEX
Code Page
Code Page
Code Page
Code Page
5M2121 HD2
5M7903 HD8
H25601A HD2
L5C4531 PD4
5M2132 HD2
5M7904 HD8
H25602A HD2
N5C8305C PD4
5M2591 HD2
5M7905 HD8
H25603A HD2
R5C4479C PD4
5M2592 HD2
5M7906 HD8
H25604A HD2
PS01 HD7
5M2593 HD2
5M7909 HD8
H25605A HD2
R5C4522 PD5
5M2594 HD2
5M7911 HD8
H25606A HD2
R5C4526 PD5
5M2595 HD2
5M9634 HD4
HCT1000B HD1
RENLSFT SO1
5M2596 HD2
5Q3810 AN4
JD01D2238 HD7
TPSURE1 HD7
5M2731 HD3
A201V801 HD4
JD01D2516 HD7
5M2732 HD3
A203V801 HD4
JD03D2238 HD7
5M2733 HD3
A204V801 HD4
L5B4825 PD2
5M2734 HD3
A209YV803 HD4
L5B4826 PD2
5M2735 HD3
A210V803 HD4
L5B4974 PD3
5M2736 HD3
A217YV806 HD4
L5B4976 PD3
5M3074 AC1
FD152530BC HD5
L5B5163 PD2
5M3121 AC1
FS1425BC HD5
L5B5166 PD2
5M3122 AC1
FS142530TP HD5
L5B5169 PD2
5M3123 AC1
FS142530TPR HD5
L5B5173 PD2
5M3134 AC1
FS1525BC HD5
L5B5177 PD2
5M5720 SO1
FS1525BCR HD5
L5B5179 PD2
5M5730 SO1
FS1532BC HD5
L5B5183 PD2
5M5730U SO1
FS152530TP HD5
L5B5187 PD2
5M6400 HD2
FS152530TPR HD5
L5B5189 PD2
5M6401 HD2
FS1625BC HD5
L5B5193 PD2
5M6402 HD2
FS1625BCR HD5
L5B5194 PD2
5M6403 HD2
FS162530TP HD5
L5B5195 PD2
5M6404 HD2
FS162530TPR HD5
L5B5202 PD2
5M6405 HD2
FS163230BC HD5
L5B5203 PD2
5M7818 HD8
FS1725BC HD5
L5B9710 PD2
5M7820 HD8
FS172530TP HD5
L5B9711 PD2
5M7821 HD8
FS172530TPR HD5
L5B9712 PD2
5M7822 HD8
FS173230BC HD5
L5B9727 PD2
5M7823 HD8
FT152530BC HD5
L5B9747 PD2
5M7824 HD8
FT153230BC HD5
L5B9770 PD2
5M7825 HD8
FT162530BC HD5
L5B9771 PD2
5M7828 HD8
FT152530BCR
HD5
L5B9772 PD2
5M7829 HD8
FT162530BCR
HD5
L5B9901 PD2
5M7856 HD8
FT142530TP HD6
L5B9902 PD2
5M7857 HD8
FT152530TP HD6
L5B9903 PD2
5M7901 HD8
FT162530TP HD6
L5C4366 PD6
5M7902 HD8
FT172530TP HD6
L5C4446 PD5
IN2
AL05121X 04/12