Form R-1041 - Institutional Or Retail Dealer Purchases Of Medical-Related Property Sales/use Exemption Certificate

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R-1041 (7/07)
Institutional or Retail Dealer Purchases of Medical-Related Property
Sales/Use Exemption Certificate
La. R.S. 47:305(D)(1) et.al., La. R.S. 47:305.2, La. R.S. 47:315.3
Taxpayer Services Division
P.O. Box 201
Baton Rouge, LA 70821-0201
(225) 219-7356 (225) 219-6236 (fax)
Please print or type.
Vendor Name
Address
City
State
ZIP
This certifi es that the tangible personal property on the attached list purchased from the above referenced vendor will be
sold or dispensed to and fully consumed by the institution’s patients or the retail customers as:
Mark one or more, as applicable:
Drugs prescribed by physicians or dentists (RS 47:305(D)(1)(j))
Orthotic, including prescription eyeglasses and contact lenses, and prosthetic devices and wheelchairs and wheel-
chair lifts prescribed by physicians, optometrists or licensed chiropractors for personal consumption or use
(RS 47:305(D)(1)(k))
Ostomy, ileostomy, or colostomy devices or appliances, including catheters or any related items, which are required as
the result of any surgical procedure by which an artifi cial opening is created in the human body for the elimination of
natural waste (RS 47:305(D)(1)(l))
Patient aids prescribed by physicians or licensed chiropractors for home use (RS 47:305(D)(1)(m))
Medical devices to be used personally and exclusively by the patients or retail customers in the medical treatment of
various diseases under the supervision of and prescribed by registered physicians (RS 47:305(D)(1)(s))
Orthodox devices, prosthetic devices, prostheses, and restorative materials utilized or prescribed by dentists in connec-
tion with health care treatment or for personal consumption or use (RS 47:305(D)(1)(t))
Insulin, both prescription or nonprescription, for personal consumption or use (RS 47:305.2)
Tangible personal property provided to a patient in a sale, lease or rental transaction, and for which the provider is
entitled to payment by or under Medicare (RS 47:315.3)
Please print or type.
Buyer
Buyer’s Address
City
State
ZIP
Authorized Representative
Title
Signature
Date (mm/dd/yyyy)

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