Form St-12b - Sales Tax Exempt Certificate For Sales Of Certain Medical Equipment

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Rev. 4/10
Form ST-12B
Massachusetts
Sales Tax Exempt Certificate for
Department of
Sales of Certain Medical Equipment
Revenue
Part A: To be Completed by Physician
I hereby prescribe the following medical equipment for the patient named below and certify that such equipment is medically necessary.
Name of patient*
Items Exempt from Sales and Use Tax When Prescribed by a Physician
Kidney dialysis machines
Canes and tripod quad canes
Enteral and parenteral feedings and feeding devices
Hospital beds for home use
Suction machines
Breast prostheses
Oxygen concentrators, regulators, humidifiers, masks and cannulas
Alternating pressure pad units
Ultrasonic nebulizers
Patient lifts
Life-sustaining resuscitators
Insulin needles and insulin syringes
Incubators
Eyeglasses
Heart pacemakers
Other_____________________________________________________
Full description of equipment
Signature of physician*
Registration number*
Address
Part B: To be Completed by Purchaser
Name of vendor
Address
Signed under the penalties of perjury.
Signature of purchaser
Address
General Information
Under Massachusetts General Laws (MGL), Chapter 64H, sec. 6(I) the
Warning: Willful misuse of this certificate is subject to criminal tax
medical equipment listed above is exempt from sales and use tax if pre-
evasion penalties of up to one year in prison and $10,000 ($50,000
scribed by a physician. The exemption covers sales, rentals and repairs
for corporations) in fines.
of these items. Vendors must collect the tax on sales of the medical
If you have any questions about the acceptance or use of this certificate,
equipment listed unless the purchaser presents this exempt certificate
please contact: Massachusetts Department of Revenue, Customer
properly completed. If the physician does not complete Part A, his or her
Service Bureau, PO Box 7010, Boston, MA 02204; (617) 887-MDOR.
written prescription form may be substituted. Vendors should attach the
prescription to this form. This patient-specific information is not required for
*This information is not required for kidney dialysis machines, which can
kidney dialysis machines. The purchaser must complete Part B. Vendors
only be used under the direction of a physician.
must retain a copy of this form with their tax records to substantiate the
exempt sale. See Massachusetts Regulation 830 CMR 62C.25.1.
This form is approved by the Commissioner of Revenue and may be reproduced.

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