Eversight Services Forms 2016 | Page 3

EVERSIGHT SERVICES SURGEON FORMS INVOICE INFORMATION SHEET Name of hospital/surgery center for billing:______________________________________________ Billing address:________________________________________________________________________ Shipping address (if different):__________________________________________________________ City, State, Zip:________________________________________________________________________ Telephone:______________________________________________ Fax:_____________________________________________________ Facility hours:___________________________________________ Delivery instructions:___________________________________________________________________ Does this facility require a Purchase Order Number for payment of tissue received? No Yes - please check all applicable boxes below: ❐ ❐ Standing PO Number:__________________________ Expires:__________ ❐ ❐ Individual PO Number:_________________________ ❐ ❐ PO Number required prior to receipt of tissue Hospital/surgery center accounts payable contact:________________________________________ Telephone:____________________ Email:________________________________________________ Hospital/surgery center purchasing dept. contact:________________________________________ Telephone:____________________ Email:________________________________________________ Hospital/surgery center operating room contact:_________________________________________ Telephone:____________________ Email:________________________________________________ Questions regarding billing? Please contact our Finance Department at [phone]. Questions regarding shipping? Please contact our Tissue Placement Department at [phone]. *Revised January 30, 2017 Tissue Placement: [phone] • Fax [phone] • [email protected]