AM Biologics Case Submission Form
Your Name
*
First Name
Last Name
Who Covered The Case?
*
Please Select
Method Medical
Astudillio Medical
Your Email
*
example@example.com
Date of Procedure
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date the procedure took place
Surgeon Last Name:
*
Astudillo Medical Surgeon Relationship?
*
Yes
No
Facility
*
Please Select
Brookwood Medical Center
Grandview Medical Center
Princeton (5% override)
UAB - Callahan
UAB - Highlands
UAB - Main
UAB - St Vincents
UAB - 119 (5% override)
UAB - St Vincents East (5% override)
UAB - West
VA Hospital (5% override)
Patient Last Name
*
How many vendors were utilized in this case?
*
Please Select
1
2
How many different products did you use?
Vendor 1 Name
*
Please Select
XCellistem (RTT Medical)
Vivex
Vendor 1 Total Case Revenue:
*
Vendor 1 Req Form Upload:
*
Browse Files
Drag and drop files here
Choose a file
Need a picture of the patients sticker and product sticker
Cancel
of
Vendor 2 Name
Please Select
XCellistem (RTT Medical)
Vivex
Vendor 2 Total Case Revenue:
Vendor 2 Req Form Upload:
Browse Files
Drag and drop files here
Choose a file
Need a picture of the patients sticker and product sticker
Cancel
of
Calculation
Submit
Should be Empty: