Acti V.A.C Therapy Information Guide Rev B June 2011

Important Patient Information

Your Nurse’s Name: _________________________________________________________ Nurse’s Telephone Number: __________________________________________________ Home Health Agency (HHA) Name: ____________________________________________ Your Doctor’s Name: ________________________________________________________ Your Doctor’s Telephone Number: _____________________________________________ In case of emergency • contact your local emergency number (i.e., 9-1-1) • contact your doctor or nurse Read and follow all instructions and safety information. Your safety is our first priority. Do not attempt to service or repair the ActiV.A.C.® Therapy Unit. If you have any problems with the unit, call KCI immediately at 1-800-275-4524. For additional safety information turn to page 18 of this guide. Important information regarding your benefits, as well as terms and conditions of use are located in the Patient Financial Responsibility - Assignment of Benefits section of this guide (page 23). Please read these carefully. Your acknowledgement on the delivery receipt indicates your agreement to these important terms and conditions of use. Important Safety Information accompanies this device. Review with your doctor or nurse prior to use. Indications, Contraindications, Warnings, Precautions and other important Safety Information are contained in the V.A.C.® Therapy Safety Information Sheet which is found and should always be kept in the pocket inside the front flap of the carrying case. If there are questions or if this information is missing, immediately contact KCI at 1-800-275-4524.

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How To Use This Book This Information Guide is designed to be a comprehensive resource for using KCI ActiV.A.C.® Therapy. Please save all pages of this guide, as you may be asked to refer to it during a KCI service call. Your doctor or nurse may also need to see certain sections for specific information regarding the therapy unit. This book is divided into five sections, each with a specific purpose:

What is ActiV.A.C.® Therapy? (page 9) / Patient Safety Information (page 18) The What is ActiV.A.C.® Therapy? section includes descriptions of how ActiV.A.C.® Therapy works, what to expect while you are using it, important patient safety information, and how to order additional supplies.

Patient Financial Responsibility (page 21) The Patient Financial Responsibility section contains information regarding your benefits, rights and responsibilities as a patient, privacy practices, and how to return your ActiV.A.C.® Therapy Unit.

Quick Reference (page 39) The Quick Reference section provides basic operating information for the ActiV.A.C.® Therapy Unit, including how turn the unit on and off, how to start therapy, how to fix a pressure leak, and how to resolve common alarms. These pages may be cut out and folded so they will fit into the pocket on the ActiV.A.C.® carrying case, or posted in a convenient location for reference by you and your doctor or nurse.

ActiV.A.C.® Patient (page 53) and Clinician User Manual (page 87) The ActiV.A.C.® User Manual will be used by both you and your doctor or nurse as a guide to all the settings and functions of the ActiV.A.C.® Therapy Unit. It describes all the buttons and screens you will see while using the therapy unit. It explains all the alarms that may occur with the ActiV.A.C.® Therapy Unit and how to resolve them. Also included is a list of frequently asked questions, and information on how to care for the therapy unit. Review this manual with your doctor or nurse at the beginning of therapy.

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Table of Contents Important Patient Information ...3 How To Use This Book ...4 What is ActiV.A.C.® Therapy? / Patient Safety Information ... 4 Patient Financial Responsibility ... 4 Quick Reference ... 4 ActiV.A.C.® Patient and Clinician User Manual ... 4

What is ActiV.A.C.® Therapy? ...9 Introduction ... 11 The ActiV.A.C.® Therapy System ... 12 What is ActiV.A.C.® Therapy? ... 12 How Does ActiV.A.C.® Therapy Work? ... 12 V.A.C.® Dressing Placement ... 13 Changing the V.A.C.® Dressing ... 13 ActiV.A.C.® Therapy Unit ... 13 ActiV.A.C.® Therapy Use ... 14 ActiV.A.C.® Therapy Settings ... 14 Ordering Additional Supplies ... 14 Hospital Admission ... 14 Questions and Answers... 15

Patient Safety Information...18 Warning – Some Patients May Have A Risk Of Bleeding ... 18 Wound Infection ... 18 Serious Infection ... 19 Allergic Reactions ... 19 Keep Therapy On For 22 Hours in 24 (Off No More Than Two Hours)... 19 Count Foam Dressing Pieces ... 19 Cover Your Cough... 19 Electrical Requirements ... 20 Fall Prevention Tips ... 20

Patient Financial Responsibility ...21 Assignment of Benefits (AOB) ... 23 Patient’s Bill of Rights and Responsibilities ... 25 Notice of Privacy Practices... 26 MEDICARE DMEPOS SUPPLIER STANDARDS... 33 Florida and Tennessee - State-Specific Addendum Sheet... 36 Maryland – State Specific Addendum Sheet ... 37 5

Rented Product Delivery and Return ... 38 Delivery of Equipment ... 38 Return of Rental Product ... 38

Quick Reference ...39 Patient Feature Identification... 41 Power Therapy Unit On or Off ... 41 Therapy On or Off ... 41 Audio Pause ... 41 Patient Mode Home Screen... 42 Carrying Case Options ... 42 Battery Charging Instructions ... 43 Battery Level Indicator ... 44 Canister ... 44 Canister Changes ... 45 Seal Check™ Leak Detector ... 46 Detecting and Resolving Common ActiV.A.C.® Therapy Alerts and Alarms... 48 Customer Contact Information ... 51

User Manual ...53 WARNING ... 55 Important Safety Information Accompanies This Device ... 55 DISCLAIMER OF WARRANTY AND LIMITATION OF REMEDY ... 55 Important Information For Users ... 56 Introduction ... 57 ActiV.A.C.® Therapy Unit ... 58 Patient Mode Home Screen ... 58 Common Screen Control Buttons ... 59 Navigation Buttons ... 59 Audio Pause ... 59 Battery Charging Instructions ... 60 Battery Charging Indicator Light ... 61 Battery Level Indicator ... 61 Canister ... 62 Canister Changes ... 62 Carrying Case ... 64 Carrying Case Options ... 65 Therapy Unit Disconnect ... 66

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Operating Instructions... 67 Power Therapy Unit On or Off ... 67 Therapy On or Off ... 67 Seal Check™ Leak Detector... 68 Finding the Leak ... 69 Alerts And Alarms ... 70 Battery Low Alert ... 71 Battery Critical Alarm ... 71 Canister Full Therapy Interrupted Alarm ... 72 Canister Not Engaged Alarm ... 73 Leak Alarm ... 74 Leak Alarm Therapy Interrupted... 75 Blockage Alert ... 76 Blockage Alarm Therapy Interrupted ... 76 Low Pressure Alert ... 77 Low Pressure Alarm Therapy Interrupted... 77 Therapy Inactive Alarm ... 78 System Error Alarm ... 78 Service Timer Expired Alert ... 79 Help Menu... 80 Change Languages ... 80 Onscreen Operating Instructions ... 80 Clinician Mode ... 81 Care And Cleaning ... 82 Standard Precautions ... 82 Waste Disposal ... 82 Cleaning the ActiV.A.C.® Therapy Unit ... 82 Cleaning the Touch Screen ... 83 Frequently Asked Questions ... 84

For Clinician Use Only ...87 Introduction ... 88 Clinician Mode Home Screen ... 89 Common Screen Control Buttons ... 90 Navigation Buttons ... 90 Audio Pause ... 90

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Operating Instructions...91 Power Therapy Unit On or Off ...91 Therapy On or Off ...91 Access Manual Therapy Settings ...91 Settings ...92 Pressure Settings ...92 Intensity Control ...92 Continuous and Intermittent Modes ...93 Intermittent Settings ...93 Settings Confirmation ...94 Settings Guide ...94 Settings Guide Confirmation ...95 Starting Therapy ...96 Seal Check™ Leak Detector...97 How to Use the Seal Check™ Leak Detector When Starting Therapy ...97 Finding the Leak Using the Seal Check™ Leak Detector ...98 Log Tool ...98 How to Use the Log Tool When Starting Therapy ...98 View Or Export Therapy History...100 View Therapy History ...100 Export Therapy History Report ...101 USB Export Issues ...101 Help Menu...102 Change Languages ...102 Onscreen Operating Instructions ...103 Change to Patient or Clinician Mode ...104 Utilities ...105 Change Time and Date...105 Change Pressure Units and Date Format ...106 Change Screen Brightness ...106 Change AC Light ...106 Care And Cleaning ...107 Standard Precautions ...107 Waste Disposal ...107 Cleaning the ActiV.A.C.® Therapy Unit ...107 Cleaning the Touch Screen ...108 Explanation Of Symbols Used ...109 Specifications ...110 Customer Contact Information ...111 8

What is ActiV.A.C.® Therapy?

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Introduction WHAT IS ACTIV.A.C.® THERAPY?

This Information Guide provides important information related to your treatment with KCI’s ActiV.A.C.® Therapy System and is a valuable reference. For additional questions or information contact your doctor or nurse, or KCI at 1-800-275-4524. Wound healing is a process Proper wound care management is important to heal your wound and your doctor has prescribed the ActiV.A.C.® Therapy System for your care. A doctor or nurse is responsible for directing the use of the ActiV.A.C.® Therapy System including application and periodic dressing changes. How long will it take to heal my wound? The length of time to heal a wound is different for every patient. General conditions, size and location of the wound, and nutritional status can affect the time it takes for a wound to heal. Your doctor or nurse will discuss when and why ActiV.A.C.® Therapy may end. What is ActiV.A.C.® Therapy? ActiV.A.C.® Therapy is KCI’s V.A.C.® Negative Pressure Wound Therapy that is provided by the ActiV.A.C.® Therapy Unit. Why V.A.C.® Therapy? V.A.C.® Negative Pressure Wound Therapy has helped to promote wound healing for millions of patients worldwide. Doctors, nurses, and hospitals all rely on V.A.C.® Therapy as an advanced wound therapy to help their patients heal.

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WHAT IS ACTIV.A.C.® THERAPY?

The ActiV.A.C.® Therapy System What is ActiV.A.C.® Therapy? ActiV.A.C.® Therapy System is a medical device system that helps wounds heal by delivering negative pressure (a vacuum) to the wound through a patented dressing and therapy unit. Unlike gauze bandages that merely cover a wound, ActiV.A.C.® Therapy actively works to help the wound healing process. The ActiV.A.C.® Therapy System helps wounds to heal by: • Promoting the formation of new granulation tissue • Providing a moist wound healing environment • Drawing wound edges together • Removing fluid and infectious materials The ActiV.A.C.® Therapy System also helps to: • Reduce wound odor • Reduce the need for daily dressing changes

How Does ActiV.A.C.® Therapy Work? The ActiV.A.C.® Therapy System is an advanced wound therapy system consisting of: • The ActiV.A.C.® Therapy unit that delivers negative pressure • A specially designed disposable canister to conveniently manage wound fluid • Sterile plastic tubing with a pressure sensing system that connects the therapy unit to the dressing • Special foam dressings (V.A.C.® GranuFoam™ and V.A.C.® WhiteFoam Dressings) that are placed in the wound, • A clear drape with adhesive (V.A.C.® Drape) that covers the foam dressing(s)

ActiV.A.C.® Therapy tubing V.A.C.® GranuFoam™ Dressing

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ActiV.A.C.® Therapy Unit and Canister V.A.C.® Drape

V.A.C.® Dressing Placement

SensaT.R.A.C.™ Pad (pressure sensing pad) V.A.C.™ Drape V.A.C.™ GranuFoam™ Dressing* Wound *If used, V.A.C.® WhiteFoam is typically recommended for placement under V.A.C.® GranuFoam™ Dressing.

Changing the V.A.C.® Dressing The ActiV.A.C.® Therapy System uses proprietary foam dressings (V.A.C.® GranuFoam™ and/or WhiteFoam) with the therapy unit. Only V.A.C.® dressings are to be used with the ActiV.A.C.® Therapy units. Wounds treated with the ActiV.A.C.® Therapy System should be monitored on a regular basis by your doctor or nurse who is responsible for treatment. • For a non-infected wound: KCI recommends the V.A.C.® Dressings be changed every 48 to 72 hours, but no less than 3 times per week. • For infected wounds: These wounds must be monitored often and very closely. Infected wounds dressing changes may need to be changed more often than 48 to72 hours. Dressing change intervals should be based on continuing evaluation of your wound condition by your doctor or nurse.

ActiV.A.C.® Therapy Unit

D B

C

A

The ActiV.A.C.® Therapy Unit is a lightweight portable device designed for patients who enjoy the freedom of being mobile. The picture shows the important features of the unit. A. Power On/Off Button B. Touch Screen User Interface C. Power Cord Connection D. ActiV.A.C.® Canister

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WHAT IS ACTIV.A.C.® THERAPY?

The V.A.C.® Dressing goes inside the wound. The wound area is sealed with the clear V.A.C.® Drape that helps maintain negative pressure over the wound. One end of the tubing connects to the dressing, the other end connects to the canister that fits into the ActiV.A.C.® Therapy Unit.

ActiV.A.C.® Therapy Use WHAT IS ACTIV.A.C.® THERAPY?

KCI recommends the ActiV.A.C.® Therapy System remain“ON at least 22 out of 24 hours per day. • If therapy is turned off for more than two hours a day, the V.A.C.® Dressing must be removed and replaced with a traditional dressing. Call your nurse or caregiver to perform this procedure. • If the unit is off for more than 15 minutes and the power to the unit is on, an alarm will sound. • If you need more time, press the AUDIO PAUSE button on the touch screen. The system will allow 60 minutes before it will alarm again. • The clear V.A.C.® Drape is waterproof. You can wash or shower with the dressings in place and with the tube clamped (closed off). Turn off the unit and unplug it from the electrical outlet. Warning: do not take the therapy unit in the bathtub or shower.

ActiV.A.C.® Therapy Settings Patient compliance with ActiV.A.C.® Therapy is important for proper healing. Your doctor will determine the negative pressure settings for your unit. Please do not change any of the settings on the ActiV.A.C.® Therapy System or remove the dressing unless told to do so by your doctor or nurse.

Ordering Additional Supplies • When you are down to one case of dressings OR five canisters, it is time to order new supplies. • To order new supplies, call KCI at 1-800-275-4524. Please allow at least 3-5 business days for delivery.

Hospital Admission Please notify KCI if you are admitted to a hospital or inpatient facility. Call KCI at 1-800-275-4524 to arrange for the pick-up of your ActiV.A.C.® Therapy System. This call stops the billing process and you will not be charged. Please contact your doctor or nurse to arrange a visit to ensure the ActiV.A.C.® Therapy Unit has been properly removed and all necessary precautions have been taken to ensure your safe transfer to the inpatient facility.

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Questions and Answers

2. Can you move around while on ActiV.A.C.® Therapy? Yes. The ActiV.A.C.® Therapy System is lightweight and was specifically designed to provide flexibility and freedom of mobility. Your ability to move around depends on your condition, the wound location and the treatment your doctor has prescribed. The ActiV.A.C.® Therapy System may be disconnected so you can take a shower. Therapy may not be off any longer than two hours per day. 3. What does the foam dressing look like when ActiV.A.C.® Therapy is on? Your doctor may prescribe a V.A.C.® GranuFoam™ or V.A.C.® WhiteFoam Dressing for your wound type. The V.A.C.® GranuFoam™ Dressing will shrink down and wrinkle like a raisin when ActiV.A.C.® Therapy is working. The V.A.C.® WhiteFoam Dressing may only have a few wrinkles. 4. Does changing the V.A.C.® Dressing hurt? Some people do experience discomfort during dressing changes depending on the wound type, location and patient condition. The discomfort is similar to other dressings and wound care treatments for the same wound type. Your doctor or nurse can give you advice about pain relief.

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WHAT IS ACTIV.A.C.® THERAPY?

1. How does ActiV.A.C.® Therapy feel? Most patients describe ActiV.A.C.® Therapy as a non-painful, mild pulling sensation that, in most cases, is not noticeable after a few minutes. Wound comfort may vary by individual person. The wound may become tender or itch as it heals; this is usually a good sign. If itching or discomfort persists, please contact your doctor.

WHAT IS ACTIV.A.C.® THERAPY?

5. Who should change my dressing, and how? Usually a nurse from your doctor’s office, home health agency or wound care clinic trained in ActiV.A.C.® Therapy, will change your dressing. If deemed appropriate by your doctor or nurse, a caregiver, family member or friend may change the dressing if they have been properly trained. To help stop the spread of germs and infection, cover your mouth and nose with a tissue when you cough or sneeze and put your used tissue in a waste basket, or cough or sneeze into your upper sleeve, not your hands. The following steps should be followed by you and/or your caregiver to reduce the risk of infection: • Caregiver should wash hands with soap and warm water for 20 seconds or clean hands with an alcohol-based hand cleaner, before and after each patient contact or procedure. • Caregiver should always wear gloves and protective clothing and eyewear when handling blood or body fluid, or when in contact with mucous membranes or open cuts. • Any caregiver with an open cut or skin condition should not care for the patient until the condition has been cleared. • Caregiver should dispose of soiled dressing according to hospital or institution protocols. Do not reuse dressing. • Caregiver should always note the total number of pieces of foam used in the wound and document on the Foam Quantity Label (if supplied) and in the patient’s chart. • Refer to application instructions provided with the dressing. 6. Who do I contact in case of an emergency? • First, call 9-1-1 (or your local emergency number). • After you call local emergency, call your doctor or nurse. • For all other medical concerns, refer to Patient Safety Information. 8. How can my caregiver be helpful? A family caregiver or friend can support you by reminding you of the importance of using ActiV.A.C.® Therapy for at least 22 hours each day. In addition, when directed by your doctor or nurse and only after proper training, your caregiver can assist in changing dressings and canisters, responding to alarms and monitoring the therapy.

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• If you are a Medicare patient and you will run out of supplies before the monthly recertification date, your nurse or doctor must complete a Letter of Medical Necessity for Excessive Supplies. 10. What do I do when my ActiV.A.C.® Therapy is completed? • Call KCI at 1-800-275-4524. • KCI will provide you instructions on how to return the ActiV.A.C.® Therapy Unit. • Billing will continue until this call is completed.

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WHAT IS ACTIV.A.C.® THERAPY?

9. How do I order supplies? • When you are down to one case of dressings OR five canisters, a new order must be called into KCI at 1-800-275-4524. Please allow at least 3-5 business days for delivery.

Patient Safety Information At KCI, your safety is our first priority. If you have questions or concerns regarding product delivery, set up or any product related issues, call KCI US Customer Support at 1-800-275-4524. • Most issues can be resolved over the phone. PATIENT SAFETY INFORMATION

• If the issue cannot be resolved over the phone, US Customer Support can provide additional assistance. Your doctor or nurse has more information about your wound. Ask your doctor or nurse for any additional information you may need before using this product. Do not change the settings on the therapy unit without your doctor or nurse giving you specific direction. Important

If deemed appropriate by your nurse or doctor, a caregiver, family member or friend may change the dressing if they have been trained by a doctor or nurse. Warning – Some Patients May Have A Risk Of Bleeding If you have recently had heart surgery, or surgery on blood vessels, or are on blood thinners, you may have a higher risk of bleeding, whether you are using ActiV.A.C.® Therapy or not. If you see a sudden increase or a large amount of blood from your wound in the tubing or canister: • Turn OFF the therapy unit right away.

Bleeding

• Apply pressure over the area. • Do not remove your dressing. • Call 9-1-1 (or local emergency number) and then notify your doctor or nurse. Wound Infection If you have an infected wound, your doctor or nurse will decide the right treatment for you. Your dressing should be changed more frequently.

Wound Infections

Call your doctor or nurse right away if you think your wound is infected or if the following symptoms worsen or develop: • You have a fever • Your wound is sore, red or swollen • Your skin itches or you have a rash or redness around the wound • The area in or around the wound feels very warm • You have pus or a bad smell coming from the wound

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Serious Infection Sometimes a wound infection can spread throughout the rest of the body. Call your doctor or nurse right away if you have any of the following symptoms: • You are sick to your stomach or throwing up • You are dizzy or feel faint when you stand up Serious Infections

• You have a headache

• Your throat is sore

• You have a rash

• You feel confused

• You have a fever over 102°F

Allergic Reactions V.A.C.® Dressings, V.A.C.® Drape and V.A.C.® Canisters are latex-free and delivered sterile. Use dressings only from unopened packages, use only once and then throw them away. The V.A.C.® Drape (dressing cover) has a coating that may cause an allergic reaction if you are allergic or sensitive to some glues. Call your doctor or nurse right away if you have any of the following signs: • Redness

• Rash or hives

• Swelling

• Severe itching

If you have difficulty breathing, seek immediate Emergency Medical Assistance, call 9-1-1 (or local emergency number).

ActiV.A.C.® Therapy Unit

Keep Therapy On For 22 Hours in 24 (Off No More Than Two Hours) Never leave a V.A.C.® Dressing in place without active ActiV.A.C.® Therapy for more than two hours. If therapy is off for more than two hours, contact your nurse or caregiver to have the old dressing removed and the wound irrigated. A new V.A.C.® Dressing from an unopened sterile package should be applied and ActiV.A.C.® Therapy started again, or an alternative dressing should be applied at the direction of the treating nurse or doctor. Call your nurse or caregiver to have this done.

V.A.C.® Simplace™ Dressing

Count Foam Dressing Pieces Your doctor, nurse, or trained caregiver should count the number of foam pieces put into your wound, and document the foam quantity and dressing change date on the drape or Foam Quantity Label if available, and in your chart. Make sure that the same number of foam pieces are removed during your dressing change. Cover Your Cough Cover your mouth and nose with a tissue when you cough or sneezze, or cough or sneeze into your upper sleeve, not into your hands. Put your used tissue in the waste basket. Clean your hands after coughing or sneezing. Wash hands with soap and warm water for 20 seconds, or clean with alcohol-based cleaner. 19

PATIENT SAFETY INFORMATION

V.A.C.® Disposables

• You have diarrhea

Electrical Requirements A three-pronged electrical outlet is recommended for use with this product. If you do not have a three-pronged outlet, use a three-pronged adapter. For safe use of the adapter, secure the ground wire to the center screw of the outlet cover plate. • Extension cords are not recommended for use with this product. • Do not overload your electrical outlets. • Keep electrical cords out of traffic areas. • Do not spill liquids on the ActiV.A.C.® Therapy Unit; it must remain dry. Fall Prevention Tips The following safety tips should be used to help prevent a patient falling or slipping while using the ActiV.A.C.® Therapy Unit: • Know your surroundings and avoid possible tripping hazards, such as throw rugs, extension cords, and uneven floors. • Position the ActiV.A.C.® Therapy Unit electrical cord so that it is not a tripping hazard. When not using the electrical cord (therapy is off or in battery mode) make sure the electrical cord is unplugged and put away. • Safely store excess electrical cord and any extra tubing and secure it to prevent tripping (See the therapy unit user manual on how to properly secure tubing). • Be cautious of door knobs and other household objects that could catch on exposed tubing. • Be careful when getting into and out of bed. When practical, have a caregiver or a capable family member present to provide assistance. • For hospital bed use: if there is a hospital bed in your home, consult the bed manufacturer’s instructions for use and your doctor or nurse about keeping the bed in the lowest practical position. Also, if your doctor has ordered the use of hospital bed rails in your home, it is recommended that you have them fully raised when a nurse or family caregiver is not present. For operating instructions and safety information, please refer to the: • ActiV.A.C.® Therapy System Quick Reference document (located in this guide) • ActiV.A.C.® Therapy System User Manual (located at the back of this guide) • V.A.C.® Therapy Safety Information Sheet (located in the carrying case pocket; see illustration on page 64) If you have a concern regarding safety or the quality of services you are receiving from KCI, you may file a complaint by calling 1-800-275-4524. If you believe that your concern was not adequately addressed you can contact KCI’s accreditation organization, The Joint Commission at 1-800-994-6610.

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Assignment of Benefits (AOB) The following is a copy of the Assignment of Benefits (AOB) you received with your V.A.C.® Therapy Unit. This form allows KCI to work directly with your insurance company, eliminating any inconveniences. Without a signed AOB, KCI cannot bill your insurance company, which may result in direct patient billing. I give KCI USA, Inc. (“KCI”) the right to bill for and receive insurance payments for my medical care and I direct my insurance company, Medicare, Medicaid, and any other entity paying for my medical care (“my insurer”) to pay KCI directly for the equipment and supplies provided to me. PATIENT FINANCIAL RESPONSIBILITY

1. I understand that ownership of the equipment shall at all times remain the property of KCI USA, Inc, unless I qualify for and agree to purchase the equipment. KCI shall have the right to inspect the equipment wherever the same may be and that I may be responsible for the replacement value of the KCI rental product in the event it is lost, damaged, or stolen while in my possession or control. 2. I understand that my insurer may need information about my medical condition to make a decision about making payments to KCI. This information may be maintained by my physician, home healthcare agency, medical facility, employer, or other entities. I authorize any holder of medical information about conditions for which I am being treated to release that information to KCI and insurer. 3. I understand that I am responsible for reading, signing, and returning the Assignment of Benefits form to KCI USA, Inc.; if not returned, I assume full responsibility of all financial charges associated to my therapy treatment provided by KCI USA, Inc. 4. I understand that KCI, my insurer, healthcare provider and other entities involved in my medical care may need certain individually identifiable financial or health information to assist in my care. I agree that such information may be used and disclosed by KCI, my insurer, healthcare providers, and other entities for purposes of treatment, payment, healthcare operations or as otherwise permitted by law. I understand that additional information on types of uses and disclosures that may be made are contained in KCI’s Notice of Privacy Practices. I understand that I may revoke my consent at any time if I do so in writing, except to the extent such consent has already been relied upon. 5. For Medicare/Medicaid Beneficiaries: I understand that I am responsible for any and all deductibles or co-payments established by Medicare or Medicaid. This information has been explained to me. 23

6. For all other insurance coverage: I understand that I am responsible for all deductibles, co-payments, or other amounts established by my insurance company, as well as all charges for non-covered services provided to me by KCI. This information has been explained to me. 7. I have received a copy of the Patient Information Guide (which includes KCI’s Notice of Privacy Practices, Supplier Standards [for Medicare] and product information and instructions). 8. I understand the care and utilization of this product and know that I can contact KCI USA, Inc. at 1-800-275-4524 for additional information.

PATIENT FINANCIAL RESPONSIBILITY

9. In the event that my insurer pays me directly, I agree to forward all payments to KCI USA, Inc., P.O. Box 203084, Houston, TX, 77216-3084. 10. I understand: (i) KCI has the option to provide new or used equipment; (ii) that I shall not modify or alter the equipment; (iii) that I will notify KCI immediately of any equipment problems; (iv) that the equipment is only to be used upon the order and direction of my doctor; (v) that the equipment is only to be used with KCI authorized disposables (i.e., dressings). 11. I understand that the equipment rental charges will continue until the date I call KCI USA, Inc. at 1-800-275-4524 to pick up the rental product. Additional Terms Governing Use, Return, and Payment: i. In the event of patient’s default in payment, or the default of patient’s insurer, health benefit plan or other third party payor, KCI shall be entitled to recover the equipment and shall not be liable to the patient or to the patient’s representatives or heirs for any injury or damage resulting from the discontinuation of treatment with the equipment. ii. KCI shall be entitled to all expenses, court costs, and reasonable attorney fees for the collection of any patient responsibility amounts that are past due and to enforcement of this AOB. All past amounts shall bear interest at the lesser of 1.5% per month or at the highest rate permitted by law. iii. This AOB and any dispute arising out of the goods and services provided shall be governed and construed according to the laws of the State of Texas without regard to its conflict of laws provision, and venue shall lie exclusively with a court of proper jurisdiction in Texas. Any dispute arising out of this Agreement shall be resolved by binding arbitration in accordance with the rules of the Judicial Arbitration and Mediation Services (JAMS).

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