ATIOL Patient Satisfaction Program Request Form

This form may be used by a healthcare practice or institution to request replacement of an Advanced Technology Intraocular Lens (ATIOL) that has been explanted from a patient by a licensed U.S. physician. Requestors that satisfy the relevant criteria will be permitted to receive partial credit for the explanted ATIOL from Alcon in the amount of the actual purchase price minus $150. Requestors will typically be notified of whether their request has been approved within 10 business days.

If you have any questions regarding this form, please contact Customer Service at 800-862-5266 or email [email protected]

Please complete each of the fields below. *Denotes mandatory fields.

Contact Information (Person completing this request):

Requestor Information:

Procedure Information:

*Is the explanted lens available for return?

Yes

Name of surgeon performing ATIOL explantation

I certify that I have authority to submit this information on behalf of the Requestor, and that this information is being provided to Alcon solely for the purpose of Alcon determining whether the Requestor is eligible to obtain a partial credit for a replacement ATIOL.

I further certify that:

I have reviewed Requestor’s books and records to confirm that the information provided in this form is accurate, and that an Alcon ATIOL was implanted and subsequently explanted from the Patient on or about the dates listed above;
If the Patient received a monofocal IOL after explantation of the initial ATIOL, Requestor has refunded the patient an amount equal to the out-of-pocket charges that Patient incurred in connection with the ATIOL implantation (charges that would not have been assessed if the Patient initially received a monofocal IOL);
If the Patient received a replacement ATIOL after explanation of the initial ATIOL, Requestor has not charged the patient any additional out-of-pocket fees attributable to Patient’s selection of an ATIOL for the replacement lens;
Requestor consents to the disclosure of the information in this Request to Alcon’s Medical Safety department. If Alcon determines that the facts described herein represent a potential adverse event or product complaint that merits additional investigation by Alcon, Alcon’s Medical Safety department may follow up to request additional information that in Alcon’s judgment is reasonably necessary to meet its obligations under relevant laws and regulations;
Any agreement by Alcon to provide partial credit for a replacement ATIOL is not intended to be, nor shall it be construed as, an offer or payment made, whether directly or indirectly, to induce the referral of patients, the prescription, purchase, lease, or order of any item or service, or the recommending or arranging for the purchase, lease, or order of any item or service.
I understand that this request is contingent upon Alcon’s written approval, and that I will be notified if Alcon determines that Requestor is eligible to receive a partial credit for replacement as for above.
Approval of this request shall not be construed as an admission or an endorsement from Alcon that the explantation procedure is medically necessary, or that the original lens had any defect. Additionally, approval of this request by Alcon does not in any way constitute an admission by either party as to potential liability that may arise from implantation and explantation procedures described.