Notification - Direct Deposit Setup Requested

Please refer to our Family Services Guide for details of the documentation required for each type of expense and payment.

Enter COTA Patient Name*

First Last

What is the patients current transplant status?*

Hospital Name*

Transplant-Related Medical Expenses

Do you have transplant-related MEDICAL expenses to submit?*

(Travel and Non-Medical Transplant-Related expenses should be added in the next two sections)

Yes
No

Medical Expense(s) Selection

RX Co-Pay(s)
Provider Co-Pay(s)
Over the Counter Medication(s)
Other Medical Expense(s) - Please Describe

Please check a box for each type of transplant-related medical expense you wish to submit.

RX Co-Pay(s)*

Enter total $ amount for all RX Co-Pay(s).

Date of Expense(s)*

Add attachment for each expense claimed. (5 max)*

Drop files here or

Provider Co-Pay(s)*

Enter total $ amount for all Provider Co-Pay(s) to be submitted.

Date of Expense(s)*

Add attachment for each expense claimed. (5 max)*

Drop files here or

Over The Counter Medication(s)*

Enter total $ amount for all OTC Medication(s).

Date of Expense(s)*

Add attachment for each expense claimed. (5 max)*

Drop files here or

Please describe other expense(s)

Other Medical Expense Amount*

Enter total $ amount for all Other Medical Expense(s).

Beginning Date of Expense(s)*

Ending Date of Expense(s)*

Add attachment for each expense claimed. (5 max)*

Drop files here or

Total Medical Expenses Submitted

Transplant-Related Travel Expenses

Do you have transplant-related travel expenses to submit?*

(Food, Transportation, Lodging, etc.)

Yes
No

Please attach documentation of each transplant-related appointment or hospitalization that you plan to include an expense for below.*

Each expense claimed below will need to reflect a date or date range that corresponds to the date of this transplant-related appointment or hospitalization in order to be approved.

Drop files here or

Travel Expenses

Food
Transportation
Lodging
Other - Please Describe
Mileage

Choose all that apply

Dollar amount for Food*

Beginning Date of Expense(s)*

Ending Date of Expense(s)*

Add attachment for each Food expense claimed. (5 max)*

Drop files here or

Dollar amount for Transportation Expenses.*

Beginning Date of Expense(s)*

Ending Date of Expense(s)*

Add attachment for each expense claimed for Transportation Expenses. (5 max)*

Drop files here or

Dollar amount for Lodging Expenses*

Beginning Date of Expense(s)*

Ending Date of Expense(s)*

Add attachment for each expense claimed for Lodging Expenses. (5 max)*

Please attach a receipt for each expense claimed in this category.

Drop files here or

Please describe other expense(s)*

Dollar amount for Other Expenses claimed.*

Beginning Date of Expense(s)*

Ending Date of Expense(s)*

Add attachment for each expense claimed for Other Expense(s). (5 max)*

Drop files here or

Mileage*

Enter Number of Miles Driven for Transplant-Related Trips

Mileage Cost Calculator

Calculated at 22 cents per mile.

Beginning Date of Expense(s)*

Ending Date of Expense(s)*

Total Travel Expenses Submitted.

Other Transplant-Related Non-Medical Expenses

Do you have other transplant-related non-medical expenses to submit?*

(Insurance Premiums, Living Expenses at Transplant, etc.)

Yes
No

Beginning Date of Expense(s)*

Ending Date of Expense(s)*