Surgeon Confirmation Form for ASR™Hip System Revision

Patient details

Patient Name:

Patient Claim Numberfrom Crawford:

Details of Primary Surgery

Can you confirm that the patient received an ASR Hip System? Yes  / No 

If the patient has an ASR Resurfacing implant, complete sections 1a1b
If the patient has an ASR XL implant complete all sections below
Section 1a / Section 1b
Cup / Head
Product Name: / / Product Name: /
Product Number: / / Product Number: /
Lot Code: / / Lot Code: /
Section 1c
Taper Sleeve / Stem
Product Name: / / Product Name: /
Product Number: / / Product Number: /
Lot Code: / / Lot Code: /

Note: If the lot code and part number areunavailable,an x-ray must be provided.

______

Please specify the date of primary surgery:______

Please specify the hospital where the primary surgerywas performed:

Please specify the surgeon who performed the primary surgery:

Diagnostic Tests Completed

What testing has been performed to verify the need for revision surgery?Tick all that apply:

Imaging completed:
X-rays
MRI
Ultrasound
CT
Blood metal ion test completed
Other, please specify:

Details of Revision Surgery

Has the revision surgery been performed?Yes  No  If yes, date:

If the revision surgery has not been performed, what is the projected/planned date of surgery?

Please specify the hospital where the revision surgeryhas been/ will be performed:

Please specify the reason(s) for revision including all contributing factors(tick all that apply):

Component Loosening
Pain
Component Malalignment
Noise
Dislocations (not arising from traumatic event)
ALVAL/ Soft Tissue Reaction
Infection (tested and positive culture confirmed)
Femoral neck fracture on resurfacing (within 3 months post op)
Femoral neck fracture on resurfacing (beyond3 months post op)
Trauma
Other reason, please specify: PLEASE PRINT

Consent & Confirmation

Yes No

I have provided a copy of the revision operative report to

Crawford to allow verification of the information included in this form.

I have obtained a signed patient consent form and provided

it to Crawford.

I have attached the relevant invoices and the invoice numbers are:

Any other relevant information that you would like to provide: ______

______

Terms & Conditions

These Terms and Conditions apply to the reimbursement of the reasonable and customary costs of revision surgery associated with the ASR recall claimed under this Surgeon Confirmation Form.

DePuy International Ltd. (“DePuy”) will reimburse you for those costs of revision surgery associated with the ASR recall to the extent that they are reasonable and customary and satisfy DePuy’s Reimbursement Guidelines
(DPY OUS 8), as such guidelines may be amended by DePuy from time to time.

All requests for payments made in the Surgeon Confirmation Formrepresent only the costs of revision surgery incurred in relation to the voluntary recall of ASR™ XL Acetabular System and DePuy ASR™ Hip Resurfacing System.

Any payments made under these Terms and Conditions will be assessed by DePuy based on confirmation by DePuy that the payment represents a reasonable and customary cost for the type of treatment claimed. Any payments made are not based on the value or volume of any business you generate for DePuy or its affiliates.

You represent, warrant, and agree that:

  1. The information you have provided in and with the Surgeon Confirmation Form is accurate and not misleading.
  1. Each request for payment made in the Surgeon Confirmation Form representsa customary cost for the treatment in question.
  1. You will retain any documentation that supports the information provided in the Surgeon Confirmation Form for at least 24 months after you submit theSurgeon Confirmation Form.

You acknowledge and accept that:

  1. Payment under the Surgeon Confirmation Form(including these Terms and Conditions) is not intended to establish an obligation for you to order, purchase, use, or recommend use of DePuy’s products.
  1. DePuy properly and reasonably relies upon your representations, warranties, and agreements for purposes of making payments pursuant to the Surgeon Confirmation Formand these Terms and Conditions.
  1. Payments under the Surgeon Confirmation Form are without prejudice and without an admission of liability by DePuy regarding any claim(s) involving the DePuy ASR Hip Resurfacing System and ASR XL Acetabular System.

YOU ARE NOT WAIVING YOUR RIGHTS OR ANY PATIENT’S RIGHTS TO PURSUE LEGAL ACTION BY SIGNING THIS SURGEON CONFIRMATION FORM (INCLUDING THESE TERMS AND CONDITIONS), PROVIDING THE INFORMATION OR DOCUMENTS, OR ACCEPTING REIMBURSEMENT FOR ANY REVISION.

Any and all disputes arising from any payments you request under the Surgeon Confirmation Formwill be determined in accordance with the laws of England and Wales and subject to the exclusive jurisdiction of its Courts.

Surgeon Name: ______Surgeon Signature: ______

Date: ______

DPYOUS –57V1 – 16122010 – EN