FLOWERAMNIOFLO · 2021. 1. 5. · Flower Orthopedics contracts with an independent, HIPAA compliant, third-party to provide insurance verification to its customers. Flower Orthopedics

FOC 1033 REV F

FLOWERAMNIOFLO™Rebate Program

VERIFICATION OF INSURANCE COVERAGE• Determine if FlowerAmnioFlo is medically necessary• Submit a completed Insurance V erification Request (IVR) form directly to our contracted,

third-party, reimbursement support team fax line at 267.803.6020• The contracted reimbursement support team will verify insurance coverage and return a

patient verification summary

FLOWERAMNIOFLO ORDER PLACEMENT • Fax completed FlowerAmnioPatch Order Form to 215.394.8904 • or email [email protected]

Each order shipment will include:• FlowerAmnioFlo• Invoice Statement• FlowerAmnio Log

FLOWERAMNIOFLO™ REBATE PROGRAM OVERVIEW

GRAFT APPLICATION

• Treat the patient as medically necessary• Use of the product is at the sole discretion of the treating physician

PAYMENT AND REBATE

• Billing Statement will be provided at the end of each month• Rebate will be issued if the eligibility requirements are met as outlined in the executed

Fulfillment Agreement• Flower charges the credit card on file per Fulfillment Agreement terms

FOR MORE INFORMATION, CALL 877.778.8904 OR VISIT WWW.FLOWERORTHO.COM FLOWER ORTHOPEDICS CORPORATION

100 WITMER RD | SUITE 280 | HORSHAM, PA 19044©2020 ALL RIGHTS RESERVED

FLOWERAMNIOFLO™WOUND CARE REIMBURSEMENT SERVICES

Benefits VerificationVerify patient eligibility, deductible, and/or co-pay

Coding AssistanceAccess to specialty billing and coverage expertise

Speak to a Real Person

Get live help when you need it

Our reimbursement team is here to help!

Learn more about our contracted, wound care

reimbursement services managed by a HIPAA

compliant, third party provider, by calling the

billing and coding hotline at 800-901-6264 or by emailing [email protected].

Flower Orthopedics contracts with an independent, HIPAA compliant, third-party to provide insurance verification to its customers. Flower Orthopedics does not collect Protected Health Information (PHI). All relevant PHI is sent directly to the third-party service provider.

FlowerAmnioFloTM Rebate Fulfillment Agreement - Multisite

This FlowerAmnioFlo Rebate Fulfillment Agreement (the “Agreement”) is entered into as of this day of , 20 (the “Effective Date”) between Flower Orthopedics, Corporation (“Flower Orthopedics”) and

Provider Name:

Having offices at the following locations (if additional locations are needed, please add an addendum):

Office Address:

Office Address:

Office Address:

(“Customer”).

Background

Flower Orthopedics is a nationwide supplier of orthopedic implants and wound care including FlowerAmnioFloTM and FlowerAmnioPatchTM. The Customer wishes to purchase FlowerAmnioFlo and Flower Orthopedics has agreed to sell to Customer the FlowerAmnioFlo subject to the following terms.

Now, therefore, the parties agree as follows:

1. Product Prices. FlowerAmnioFlo means the wound care products offered by Flower Orthopedics as described inSchedule A, as such Schedule may be modified from time to time. The "Invoice Price" for a FlowerAmnioFlo is theprice stated for that FlowerAmnioFlo in Schedule A.

2. Insurance Verification. Customer agrees to utilize Flower Orthopedics’ Insurance Verification Request form (IVR)prior to ordering and using FlowerAmnioFlo.

3. Order Fulfillment. After Customer submits an IVR and receives confirmation of patient’s benefits, the Customerplaces an order and Flower Orthopedics accepts the order and generates an Invoice Statement, which willreflect that the Customer has agreed to purchase the Products identified on the Statement and the terms of thepurchase. Flower Orthopedics shall, on Customer's behalf, promptly pack and ship the FlowerAmnioFloidentified on the Statement for delivery to the Customer using priority overnight delivery. Flower Orthopedicsshall provide delivery status information from the carrier to the Customer for shipment.

4. Product Usage. After receiving FlowerAmnioFlo, Customer will treat the patient as medically necessary.Customer and Flower acknowledge that use of the product is at the sole discretion of the treating physician,pursuant to their professional medical judgment.

5. Rebate Qualification. If the Customer purchases three (3) or more FlowerAmnioFlo in a given calendar month, they will qualify for a rebate on all FlowerAmnioFlo purchased for that calendar month. Eligibility for the rebate for each calendar month will be calculated at the end of the calendar month and, if the Customer is eligible for a rebate for that calendar month, the amount of the rebate earned will be applied to the Customer’s account as a credit. Customer agrees to fully and accurately report all amounts paid and rebates earned hereunder to Medicare, Medicaid and all other federal and state health care programs and third-party payers, as required by applicable law or agreement, and to provide copies of this Agreement and all other applicable documentation and invoices to representatives of these programs and other third-party payers upon their request. At the end of each year, Flower Orthopedics will send Customer a statement detailing the number of each type of FlowerAmnioFlo ordered by Customer during that period, and the aggregate amount Customer paid for such FlowerAmnioFlo net of any earned rebates and Customer agrees to make that statement available upon request to the payor.

6. Invoices & Payment. Customer will be invoiced upon product shipment. At the end of each calendar month, Flower Orthopedics will develop and deliver a monthly Billing Statement to Customer that accurately identifies the Products ordered in that calendar month and the Customer’s outstanding balance, which shall reflect the Invoice Price of the Products ordered and not yet paid by the Customer, as well as any rebates that the Customer has earned as of the date of the invoice, and any other charges or credits on the Customer’s account to date. Flower Orthopedics will make commercially reasonable efforts to reflect rebates earned by the Customer in each calendar month on the Customer’s Billing Statement. In any case, however, Customer agrees to pay Flower Orthopedics the amount stated in each Billing Statement within thirty (30) days of the date of the Billing Statement. Customer agrees to provide Credit Card Authorization for payment of all Billing Statements.

7. Authorized Users. The Customer may choose to provide Flower Orthopedics with a list of Authorized Users in addition to the Provider named above, which the Customer shall provide by listing such Authorized Users in the space provided below. The Customer may add or remove Authorized Users at its option by notifying Flower Orthopedics in writing of such changes to the list of Authorized Users, and such changes shall be effective for purposes of this Agreement at the beginning of the month following Flower Orthopedics’ receipt of notice. The list of Authorized Users, as may be amended from time to time by such notice from the Customer, shall be incorporated into and part of this Agreement. Flower Orthopedics shall consider an order submitted according to this Agreement by any Authorized User to be an order submitted by the Customer, and the Customer shall be liable for payment for such orders under the terms of this Agreement. In addition, purchase of FlowerAmnioFlo by an Authorized User shall be eligible to contribute to the monthly Rebate Qualification detailed in Section 5 above.

8. Miscellaneous. This Agreement contains the entire agreement between the Parties concerning the subject matter hereof and is governed by Pennsylvania law. This agreement may be amended or modified only by a written agreement signed by both parties.Executed as of the Effective Date.

Flower Orthopedics, Corporation Customer

By: By:

Schedule A

Products and Prices

Part Number

Description Units Unit Price

Invoice Price

Q41

77

FBF 051 FlowerAmnioFlo 0.5ml - 5 units (Q4177) 5 $180 $900

FBF 101 FlowerAmnioFlo 1.0ml - 10 units (Q4177) 10 $180 $1,800

FBF 201 FlowerAmnioFlo 2.0ml - 20 units (Q4177) 20 $180 $3,600

Credit Card Authorization Form

Please sign and complete this form to authorize Flower Orthopedics Corporation to apply charges to your credit card listed below.

By signing this form, you grant Flower Orthopedics Corporation permission to charge the credit card below for the monthly Billing Statement after 30 days, unless payment is received otherwise.

Please complete the information below:

I (Full Name) authorize Flower Orthopedics Corporation to charge my credit card account for Billing Statement as indicated above.

Credit Card Authorization

Signature: Date:

I authorize the above-named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above. I certify that I am an authorized user of this credit card and that I will not dispute the payments with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

PROVIDER NAME:

CREDIT CARD TYPE: AMEX VISA MASTERCARD

CREDIT CARD NUMBER:

Expiration Date:

CVV:

EMAIL:

*Patient Name: *DOB: □ Male □ Female

Address: City: State: Zip:

Home Phone #: Mobile #:

*Is this patient currently in a skilled facility or nursing home? □ Yes □ NoIf YES, how many days has the patient been admitted to the skilled nursing facility or nursing home?

Primary Insurance: Secondary Insurance:

Payer Phone #: Payer Phone:

Policy Number: Policy Number:

Subscriber Name: Subscriber Name:

Specialty:

*Provider ID #s: NPI:* Tax ID: Medicaid

*Facility Name:

Address: City:

*Facility ID #s: NPI:* Tax ID:

*Facility Contact: Phone #: Fax

Email Address:

*Treatment Setting: □ Hospital Based Outpatient Wound Department/Clinic (HOPD)Flower Orthopedics does not verify benefits for procedures performed in the operation room settin

□ New Wound □ Additional Application □ Re-verification □ New Insurance

Coding and Billing

□ Q4178 FlowerAmnioPatch™

□ Diabetes □ Vascular □ Other

*ICD-10 Diagnosis Codes(Related to FlowerAmnioPatch treatment)

Secondary

Known Conditions:

Anticipated Treatment Start Date: Frequency:

If the payer requires prior authorization for pre-determination for Flower Orthopedics product appl □ Yes □ No If yes, please attach a minimum of four weeks of clinical notes

I certify that I have obtained a valid authorization under applicable law from the patient listed on protected health information (PHI), for the purpose of insurance verification; and (b) authorizing thcompliant, third-party service provider for the purposes of determining benefit coverage.

Provider Signature:_______________________________________ Date:_____________________ Sales RPlease fax this form along with a copy of the front and back of the patient’s insurance card.

FLOWERAMNIO INSURANCE VERIFICATION REQUEST Please print and Fax to: 267.803.6020

Phone: 800.901.6264

Disclaimer: Insurance verification is an information service only. Information gathered during the rethird-party payer. Results of this research are not a guarantee of coverage or reimbursement, or pay

□ 15271 □ 15275 □ Other, please specify:

*Provider Name:

Provider and Facility Information

Patient and Insurance Information

PTAN #:

□ Q4177 FlowerAmnioFlo™

□ New Injection

Primary

□ 20550 □ 20551 □

□ 20553 □ 28899 □

Required information indicated by *

Flower Orthopedics contracts with an independent, HIPAA compliant, third-party to provide insurance verification to its customers. Flower Orthopedics does not collect Protected Health Information (PHI). All relevant PHI is sent directly to the third-party service provider via a HIPAA compliant fax line. Please call 800.901.6264 to arrange for written agreements directly with the third-party service provider as required.

Provider #

State: Zip:

#:

□ Provider’s Officeg

Tertiary

Number of Applications:

ications, would you like assistance?

this form (a) permitting me to release the patient’s e payer to disclose PHI to an independent, HIPAA

epresentative:________________________________________

quested research will be provided by the insurer or ment of any claims, benefits, or costs.

PTAN #:

Wound Size

FOC 1020 Rev D

20552

Other, please specify:

FLOWER ORTHOPEDICS CORPORATION • 100 WITMER ROAD, SUITE 280 • HORSHAM, PA 19044 T:877.778.8587 • WWW.FLOWERORTHO.COM

Order Date

• This order form should be submitted after insurance has been verified using the FlowerAmnioInsurance Verification Request (IVR) form. This form can be obtained online at flowerortho.com.

• The prices reflected on this order form may be subject to a rebate, as defined in your executed Fulfillment Agreement.

Part Number Description

Invoice Price QTY

Flo

wer

Am

nio

Flo

™

Q4

17

7

FBF 051 FlowerAmnioFlo 0.50ml – 5 units (Q4177) $900

FBF 101 FlowerAmnioFlo 1.0ml – 10 units (Q4177) $1,800

FBF 201 FlowerAmnioFlo 2.0ml – 20 units (Q4177) $3,600

FOC 1032 Rev D

Patient Initials

Case ID

Requesting Provider

Provider Phone

Email

Date of Service

State

Zip Code

FLOWERAMNIOFLO™ ORDER SHEET Fax Form to 215.394.8904

Email Form to [email protected]

Shipping Address Line 1

Shipping Address Line 2

City

YOUR LOGO

Flower Orthopedics Corporation

100 Witmer Road, Suite 280

Horsham, PA 19044

1 (877) 778 8587

BILL TO SHIP TO

ATTN: John Smith ATTN: John Smith

Sample Surgery Center Sample Surgery Center

100 Witmer Road 100 Witmer Road

Horsham Pa, 19044 Horsham PA, 19044

1.877.778.8587 1.877.778.8587

[email protected] [email protected]

SHIPPING METHOD SHIPPING TERMS PATIENT INITIALS PAYMENT SURGERY DATE

FedEx Priority Overnight JS 11/13/2020

ITEM NO. DESCRIPTION QTY UNIT PRICE TOTAL

FBF 051 FlowerAmnioFlo, 0.5ml - 5 units (Q4177) 3 900.00$ 2,700.00$

-$

-$

-$

-$

-$

Remarks / Instructions: SUBTOTAL 2,700.00$

TOTAL 2,700.00$

INVOICESTATEMENT

For questions concerning this invoice, please contact

Flower Customer Service, 877.778.8587, [email protected]

www.FlowerOrtho.com

INVOICE DATE

Sample QD499

INVENTORY LOC.

181026-01

11/15/2020

PURCHASE ORDER NO.

SAMP

LE

The prices reflected on this invoice statement may be subject to a rebate, as defined in your executed Fulfillment Agreement.

Customer agrees to follow their institutional provider agreements for any amounts paid and rebates earned hereunto, as required by applicable law or institutional provider agreements.

30 Days

http://www.flowerortho.com/

YOUR LOGODATE PURCHASE ORDER NO.

11/30/2020 181026-01

Flower Orthopedics Corporation

100 Witmer Road, Suite 280

Horsham, PA 19044

1 (877) 778 8587

BILL TO SHIP TO

ATTN: John Smith ATTN: John Smith

Sample Surgery Center Sample Surgery Center

100 Witmer Road 100 Witmer Road

Horsham Pa, 19044 Horsham PA, 19044

1.877.778.8587 1.877.778.8587

[email protected] [email protected]

ORDER NUMBER ORDER DATE CUST NO TRACKING NUMBER

73858323 11/15/2020 2845 377446371938

ITEM CODE QTY ORDER QTY SHIP DESCRIPTION QTY UNIT PRICE TOTAL

FBF 051 3 3 3 900.00$ 2,700.00$

Rebate

FBF 051 3 3 REBATE -FlowerAmnioFlo, 0.5ml - 5 units (Q4177) 3 $ (270.00) $ (810.00)

SUBTOTAL 2,700.00$

REBATE $ (810.00)

TOTAL $ 1, 890.00100 Witmer Road Suite 280, Horsham PA 19044

BILLING STATEMENT

PAYMENT DUE DATE

12/30/2020

Flower Orthopedics Corporation will charge the credit card on file for the amount due if payment has not been received by the payment due date.For questions concerning this invoice, please contact

Flower Customer Service, 877.778.8587, [email protected]

www.FlowerOrtho.com

The prices reflected on this billing statement may be subject to a rebate, as defined in your executed Fulfillment Agreement.

PAYMENT TERMS

30 Days

Remit Payment To:

Customer agrees to follow their institutional provider agreements for any amounts paid and rebates earned hereunto, as required by applicable law or institutional provider agreements.

FlowerAmnioFlo, 0.5ml - 5 units (Q4177)

http://www.flowerortho.com/

123-45-6789A

06 22 1945

123 StreetSt 123 StreetSt

Anywhere PA Anywhere PA

00000 123 456-7890 00000 123 456-7890

07 15 18 07 15 18 11

107 15 18 07 15 18 11 20550

01-2345678 01234567890

$ 00

$

S

0 00

Bob Smith 7/15/18

Billing Company 123 Main StSomewhere, PA 11111

555 222-666

7/15/18

654987321

SAMPLE CMS 1500

Q4177 20

00300

Flower Orthopedics 100 Witmer RoadSuite 280Horsham, PA 19044

Phone: 215.394.8903www.FlowerOrtho.com

FOC 1033_E FlowerAmnioFlo Rebate Program_11.14_++FinalFlo+tempFLoFlowerAmnioFlo Rebate Guide - FOC 1033 Rev E

++FinalFlowerAmnioPatchRebateProgramFinalFlowerAmnioPatchRebateProgramFinalFlowerAmnioPatchRebateProgramFinalFlowerAmnioPatchRebateProgram+TempPatchRebateGuide

+tempFLo

FOC 1057_A Multisite FlowerAmnioFlo Fullfillment AgreementFlowerAmnio Rebate Fulfillment Agreement - MultisiteBackground

FOC 1057_B Multisite FlowerAmnioFlo Fullfillment AgreementFlowerAmnioFloTM Rebate Fulfillment Agreement - MultisiteBackground

FOC 1033_E FlowerAmnioFlo Rebate Program_11.14_FOC 1057_B Multisite FlowerAmnioFlo Fullfillment AgreementFOC 1033_E FlowerAmnioFlo Rebate Program_11.14_FOC 1057_A Multisite FlowerAmnioFlo Fullfillment AgreementCredit Card Authorization FormPlease sign and complete this form to authorize Flower Orthopedics Corporation to apply charges to your credit card listed below.Please complete the information below:

Credit Card Authorization

FOC 1020_D FlowerAmnio Insurance Verification Request++FinalFlo+tempFLo+tempFLoBack page

Prinect PDF Report 19.10.039 - 1 - 07/02/2019 01:06:36 PM

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FLOWERAMNIOFLO · 2021. 1. 5. · Flower Orthopedics contracts with an independent, HIPAA compliant, third-party to provide insurance verification to its customers. Flower Orthopedics