Surgeon Confirmation Form for ASR™ Hip System Revision
Patient details
Patient Name:
Patient Claim Number from Crawford:
Details of Primary Surgery
Can you confirm that the patient received an ASR Hip System? Yes  / No  
If the patient has an ASR Resurfacing implant, complete sections 1a & 1b
If the patient has an ASR XL implant complete all sections below
Section 1a
Cup
Product Name:
Product Number:
Lot Code:
Section 1b
Head
Product Name:
Product Number:
Lot Code:
Section 1c
Taper Sleeve
Product Name:
Product Number:
Lot Code:
Stem
Product Name:
Product Number:
Lot Code:
Note: If the lot code and part number are unavailable, an x-ray must be provided.
_____________________________________________________________________________________
Please specify the date of primary surgery:
________________
Please specify the hospital where the primary surgery was performed:
Please specify the surgeon who performed the primary surgery:
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Diagnostic Tests Completed
What testing has been performed to verify the need for revision surgery? Tick all that apply:
Imaging completed:
X-rays
MRI
Ultrasound
CT
Blood metal ion test completed
Other, please specify:
Details of Revision Surgery
Has the revision surgery been performed?
Yes 
No 
If yes, date:
If the revision surgery has not been performed, what is the projected/planned date of surgery?
Please specify the hospital where the revision surgery has been/ will be performed:
Please specify the reason(s) for revision including all contributing factors (tick all that apply):
Component Loosening
Pain
Component Malalignment
Noise
Dislocations (not arising from traumatic event)
ALVAL/ Soft Tissue Reaction
Infection (tested and positive culture confirmed)
Femoral neck fracture on resurfacing (within 3 months post op)
Femoral neck fracture on resurfacing (beyond 3 months post op)
Trauma
Other reason, please specify: PLEASE PRINT
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Consent & Confirmation
Yes
No
I have provided a copy of the revision operative report to
Crawford to allow verification of the information included in this form.
I have obtained a signed patient consent form and provided
it to Crawford.
I have attached the relevant invoices and the invoice numbers are:
Any other relevant information that you would like to provide: _________________________________________
________________________________________________________________________________________
Terms & Conditions
These Terms and Conditions apply to the reimbursement of the reasonable and customary costs of revision
surgery associated with the ASR recall claimed under this Surgeon Confirmation Form.
DePuy International Ltd. (“DePuy”) will reimburse you for those costs of revision surgery associated with the ASR
recall to the extent that they are reasonable and customary and satisfy DePuy’s Reimbursement Guidelines
(DPY OUS 8), as such guidelines may be amended by DePuy from time to time.
All requests for payments made in the Surgeon Confirmation Form represent only the costs of revision surgery
incurred in relation to the voluntary recall of ASR™ XL Acetabular System and DePuy ASR™ Hip Resurfacing System.
Any payments made under these Terms and Conditions will be assessed by DePuy based on confirmation by DePuy
that the payment represents a reasonable and customary cost for the type of treatment claimed. Any payments
made are not based on the value or volume of any business you generate for DePuy or its affiliates.
You represent, warrant, and agree that:
1.
The information you have provided in and with the Surgeon Confirmation Form is accurate and not
misleading.
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2.
Each request for payment made in the Surgeon Confirmation Form represents a customary cost for the
treatment in question.
3.
You will retain any documentation that supports the information provided in the Surgeon Confirmation Form
for at least 24 months after you submit the Surgeon Confirmation Form.
You acknowledge and accept that:
1.
Payment under the Surgeon Confirmation Form (including these Terms and Conditions) is not intended to
establish an obligation for you to order, purchase, use, or recommend use of DePuy’s products.
2.
DePuy properly and reasonably relies upon your representations, warranties, and agreements for purposes of
making payments pursuant to the Surgeon Confirmation Form and these Terms and Conditions.
3.
Payments under the Surgeon Confirmation Form are without prejudice and without an admission of liability by
DePuy regarding any claim(s) involving the DePuy ASR Hip Resurfacing System and ASR XL Acetabular System.
YOU ARE NOT WAIVING YOUR RIGHTS OR ANY PATIENT’S RIGHTS TO PURSUE LEGAL ACTION BY SIGNING THIS
SURGEON CONFIRMATION FORM (INCLUDING THESE TERMS AND CONDITIONS), PROVIDING THE INFORMATION
OR DOCUMENTS, OR ACCEPTING REIMBURSEMENT FOR ANY REVISION.
Any and all disputes arising from any payments you request under the Surgeon Confirmation Form will be
determined in accordance with the laws of England and Wales and subject to the exclusive jurisdiction of its
Courts.
Surgeon Name: _____________________________ Surgeon Signature: ______________________
Date: ________________________
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