Patient Agreement -Adult

COTA Patient Agreement – Adult

Step 1 of 7

Please allow 30 – 60 minutes to complete the following agreement. If at any time you prefer to save your progress and resume later, scroll to the bottom of the form and select the link to save and finish later. You can see your total progress to completion via the progress bar above.
Please review our Patient Agreement and check the box below to certify that you have read, understand, and agree with the information provided.
*
- I Agree

Patient Information
Name*
First Middle Last
Preferred Name (if applicable)
Date of Birth*
MM slash DD slash YYYY
Gender
- Male
- Female
Ethnicity
Preferred Phone Number*
Phone Number Type
Please enter email address to receive COTA communications and notifications.*
Home Address*
Street Address Address Line 2 City State ZIP Code
Primary Address COUNTY
Would you like to add a temporary address and contact number?
Temporary Address
Street Address Address Line 2 City State ZIP Code
Temporary Contact Number
Transplant Information
Diagnosis
Date of Diagnosis
MM slash DD slash YYYY
Recommended Transplant Type
Living Donor?
Please enter 'other' recommended transplant type
Are you awaiting transplant?
Have you already been transplanted?
Date Transplant Completed
MM slash DD slash YYYY
Please Enter Transplant Center
How did you learn about COTA?
Social Worker Information
Name
First Last
Phone
Social Worker Email
Transplant Coordinator Information
Name
First Last
Phone
Transplant Coordinator Email
Financial Coordinator Information
Name
First Last
Phone
Financial Coordinator Email

Family Information
Who has medical power of attorney?
First Last
What is his/her relationship to you?
Please attach a copy of the medical power of attorney.
Drop files here or

Max. file size: 98 MB, Max. files: 50.
Would you like to list your caregiver's information?
Caregiver's Name
First Last
What is the caregivers relationship to the patient?
Caregiver's Address
Street Address Address Line 2 City State ZIP Code
Preferred Phone Number
Caregiver Email Address
Present Employer
Caregiver Spouse Name
First Last
Caregiver Spouse Phone Number
Would you like to list an additional caregiver?
Caregiver Name
First Last
What is the caregivers relationship to the patient?
Address
Street Address Address Line 2 City State ZIP Code
Preferred Phone Number
Email Address
Present Employer
Caregiver Spouse Name
First Last
Caregiver Spouse Phone Number
Are there additional persons in your household?
Additional Household Member 1
Name
First Last
Date of Birth
MM slash DD slash YYYY
Relationship to patient
Add another household member?
Additional Household Member 2
Name
First Last
Date of Birth
MM slash DD slash YYYY
Relationship to patient
Add another household member?
Additional Household Member 3
Name
First Last
Date of Birth
MM slash DD slash YYYY
Relationship to patient
Add another household member?
Additional Household Member 4
Name
First Last
Date of Birth
MM slash DD slash YYYY
Relationship to patient
Family Affiliation Information
Do you belong to any religious group (church/parish/synagogue/mosque)?
Please specify group.
Have you or any member of your immediate family served in the U.S. military?
Military Family Member Relationship
Please list branch(es) served.
Is any member of your family a member of the American Legion?
Enter the American Legion post number (if known).
Do you belong to any community service organizations (Rotary, Lions Club, Kiwanas, PTO)?
Please list organization(s).
Do you belong to any patient support communities (online or in person)?
Please list group(s).
Do you have a social media presence (Facebook, Instagram, Twitter)?
Please enter the name(s) of social sites.

Volunteer Information
Community Coordinator Name (Required)*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Preferred Phone Number*
Phone Number Type
Email Address
Relationship to Patient*
The community coordinator must not live in the same home as the patient and can not be the primary caregiver at the time of transplant.
Add another volunteer?
Volunteer 2
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Add another volunteer?
Volunteer 3
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Add another volunteer?
Volunteer 4
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone

Agreement and Signature
PERMISSION TO ALLOW THE CHILDREN’S ORGAN TRANSPLANT ASSOCIATION TO ACT ON MY BEHALF
I have read the Patient Agreement and the Children’s Organ Transplant Association (“COTA”) informational materials, and I understand how funds are collected, administered and disbursed. I certify that the information I provide within this agreement is true and correct to the best of my knowledge. I authorize the Children’s Organ Transplant Association to verify any or all information, including health and life insurance through current employers for wage earners in patient household. I agree to follow the advice and required guidelines provided by COTA concerning the use of printed materials, fundraising activities, web resources and handling of funds. I give COTA permission to use the patient’s name, image, voice and medical information (including, without limitation, diagnosis, prognosis, and treatment information) for the purpose of raising funds to support transplant treatments. I further give COTA permission now and in the future to provide such information to any media outlet for the purpose of promoting fundraising and COTA’s broader mission, including increasing public awareness of COTA and its goals not only in support of my situation or campaign, but for other campaigns, or for use by COTA now and in the future. I also agree not to contact the media regarding my circumstances without first contacting COTA. I agree to exclusively utilize the official campaign website provided by COTA, and will not have another Internet site (including blogs) with patient fundraising information or content. I understand promoting the COTA campaign via social media outlets is encouraged. I understand that COTA retains the right to alter or delete any information on the campaign website which it deems, in its sole discretion, non-compliant, illegal, inappropriate or incorrect. COTA reserves the right to require edits be made on campaign social media posts that are inaccurate or misleading. I understand that medical status is an important factor in determining the eligibility for this program and/or success of the program itself. I agree to provide COTA, its employees, agents, and assigns, all medical information, including, without limitation, medical charts and medical bills, and execute all authorizations necessary to obtain such information, as COTA deems necessary to determine my eligibility for the COTA program, to conduct fundraising programs, and to allocate for eligible transplant-related expenses. These expenses are solely determined by COTA and are highlighted in the Patient Agreement. I understand that funds are the property of COTA and do not belong to the individual patient, community campaign team or patient family. I understand that this agreement may be terminated at any time for any reason by the patient/family or by the Children’s Organ Transplant Association, upon written notice.
Today's Date – Date of Agreement
MM slash DD slash YYYY
Patient / Legal Representative Signature*
First Last
I have electronically signed this agreement and agree that this is an acceptable substitute for a wet ink signature.
Relationship to Patient:
By signing my name, I certify that all information submitted is true and correct to the best of my knowledge and authorize the Children's Organ Transplant Association to verify any or all of the above information, including health and life insurance coverage through current employers.

Patient Agreement -Adult

COTA Patient Agreement – Adult

Step 1 of 7

Please allow 30 – 60 minutes to complete the following agreement. If at any time you prefer to save your progress and resume later, scroll to the bottom of the form and select the link to save and finish later. You can see your total progress to completion via the progress bar above.

Patient Information

Transplant Information

Social Worker Information

Transplant Coordinator Information

Financial Coordinator Information

Family Information

Additional Household Member 1

Additional Household Member 2

Additional Household Member 3

Additional Household Member 4

Family Affiliation Information

Combined Monthly Household Income

Estimated Total Monthly Living Expenses & Liabilities

Insurance Information

Primary Insurance

Secondary Insurance

3rd Level of Health Insurance

Volunteer Information

Volunteer 2

Volunteer 3

Volunteer 4

Agreement and Signature

PERMISSION TO ALLOW THE CHILDREN’S ORGAN TRANSPLANT ASSOCIATION TO ACT ON MY BEHALF