Get Medical Outreach Program Application: Overview - Americares - Americares

Filling out the Medical Outreach Program Application is a crucial step for physicians seeking donated products for charitable surgeries. This guide provides a clear and supportive overview of the application process, ensuring you have all the necessary information at your fingertips.

Follow the steps to complete your application effectively.

1. Press the ‘Get Form’ button to access the application document and open it in your preferred editor.
2. Begin by entering the physician’s contact information. Provide your full name, practice name, and address, including city, state, and zip code. Indicate your best telephone number and email address for communication.
3. Fill out the Zimmer Biomet representative's contact information if applicable. This section should include their name, distributor details, and contact information similar to the physician's details.
4. Next, complete the medical facility contact information. Include the name and address of the facility where the surgery will be performed, as well as a primary contact person's name and phone number.
5. In the surgery and patient information section, provide a full description of the type of surgery, the anticipated date of the surgery, the patient's age, gender, and country of citizenship.
6. Indicate whether the physician and patient are willing to participate in interviews or photography for publication purposes.
7. Document the physician's license information, including the license type, state, and expiration date. Attach a copy of the U.S. state medical license or relevant online verification if applicable.
8. Complete the Zimmer Biomet product request form by listing the required products, including complete product numbers, descriptions, and quantities. Ensure to follow instructions regarding substitutions and pricing.
9. After reviewing all information, the physician should sign and date the application affirming responsibility for the product donation and compliance with guidelines.
10. Once the application is completed, you can save your changes, download a copy, print it, or share it through email or fax to Americares at the provided contact details.

Complete your Medical Outreach Program Application online today to facilitate critical charitable surgery support.