Eversight Services Forms 2016 | Page 7

EVERSIGHT SERVICES SURGEON FORMS CHARITABLE SERVICES REQUEST This form MUST be submitted before the scheduled surgery date. Please allow at least one week for this request to be reviewed and approved. Date:______________________ Surgeon name:____________________________________________ Patient name:_________________________________________________________________________ Date & location of surgery:_____________________________________________________________ Reason the patient needs gratis or reduced-fee tissue: ____________________________________ ______________________________________________________________________________________ Does the patient have insurance? Yes No Does the patient receive Medicare? Yes No Does the patient receive Medicaid? Yes No State reimbursement:___________________ Financial assistance from providers 1) Surgeon's fee reduced by:______% 2) Hospital/surgery center's fee reduced by:_____% 3) Anesthesiologist's fee reduced by:______% 3) Requested financial aid from Eversight:______% Contact name:_____________________________________ Contact phone:____________________ I verify that this patient demonstrates financial need for charitable services. As part of our mission to restore sight, Eversight and its affiliates rely on financial contributions to provide charitable support for uninsured or underinsured patients in need of a cornea transplant. These charitable contributions are used to offset all or a portion of the reimbursement fees related to tissue recovery and processing for transplantation. For Eversight use only Request received by:___________________________________________________________________ Request reviewed by:__________________________________________________________________ Status: Approved Declined Date:_______________________ Invoice tissue at:_______________________________________________________________________ Comments:___________________________________________________________________________ *Revised January 30, 2017 Tissue Placement: [phone] • Fax [phone] • [email protected]