Lilly Radiopharmaceutical Product Loss Claim Form

In date Lilly Radiopharmaceutical Products which require administration by an authorized imaging facility may be eligible for product credit. Please reference the Lilly Return Goods Procedure for eligibility criteria. This form must be completed in its entirety. The claim request may take up to 10 business days to review. For questions, email: Lillytrade@lilly.com

Date

Imaging Center Name*

Street Address*

City*

State*

Zip Code*

Imaging Center Email Address*

Email address of contact at the imaging center managing loss claim submission.

Phone Number*

Phone Number of imaging center or a contact at the imaging center.

RX Number*

Product Name*

Date of Product Loss*

Reason for Product Loss*:

Patient No Show/Late: Unable to to be administered due to failure of patient to attend their previously confirmed scheduled appointment or late arrival

Medical Reason: Inability to administer for medical or clinical reasons (e.g., claustrophobia, inability to locate vein, etc.) where the failure to administer is not caused by the fault of the imaging center

Other

Provide a detailed explanation of how product loss occurred* 0 / 500

User Certification*:

^{Please read the following before signing and submitting the form. By signing and submitting this form, the entity submitting certifies to the following:}

^{That the entered information is correct to the best of my knowledge and I have complied with the terms of the Lilly Return Goods Procedure.}
^{That the product dose listed above was not administered to the patient and disposed of in accordance with local, state, and federal regulations and I will not seek reimbursement or payment from the patient, payor, or any other third party for the products listed above.}
^{That I agree to maintain records for at least 3 years (or such longer duration as may be required by law) from the signature date on this form that validate my compliance with all certifications that I’ve made in this form and that I will permit Lilly, upon its written request, either by itself or through a third party, to audit such records as reasonably necessary to confirm my compliance with the certifications that I’ve made in this form; and}
^{That I understand that the reimbursement that is being sought under this form is subject to the Lilly Return Goods Procedure set forth and I further understand and acknowledge that such Returns Procedure supersedes and terminates any previous policy or programs (through agreements or otherwise), if any, that I may have previously used or relied on with respect to returns/reimbursement from Lilly in connection with Lilly product when such product was determined unusable.}

I understand Eli Lilly and Company retains the right to discontinue the procedure that this form relates to for a particular account/physician, where it determines, in its sole discretion, any such account/physician has misused this policy. In cases of misuse, Eli Lilly and Company reserves the right to reverse a return or charge an account for product previously reimbursed. Eli Lilly and Company has the right to modify or discontinue this program at any time without notice.

Signature*