Charitable Mission Product Contributions and Request Form
Patient Assistance Product Contributions and Request Form
Product Charitable Contribution Criteria
Sales Personnel Assistance Required to Prepare Product Request Lists
Product Contributions Involve Special and Unique Challenges
Limited Availability of Biologic Products for Contributions
China Charitable Mission Issues
Business Conduct Standards Brochure

Charitable Mission Product Contributions and Request Form
Many of Medtronic Sofamor Danek's Customers generously contribute their time by visiting underserved communities - frequently in other countries - and performing several surgeries during a 1-3 week period of time. MSD is committed to providing contributions of its products for these charitable missions.

To download a Word version of the Charitable Mission Product Charitable Contribution Request Form, click on the link at the bottom of this section.

MSD's charitable contribution request forms are formatted with MicroSoft's form tool. To complete the request form:

• Move to each field that needs to be completed by using the Tab button or a moving your curser to the next field.
• If the field is a box, then just click on the appropriate box to place an "x" in the box.
• If the field is a gray text area (it is empty white space in a printed version of the form), simply start typing in the requested information.
• If you need to unlock the form to add information that does not have a box or text field: (1) select "View" on the top menu bar, (2) select "Toolbars", (3) select the "Forms" toolbar. Once the toolbar is added, click on the icon that looks like a padlock so it is no longer highlighted. You can then type anywhere on this document. If you click on the padlock again, you may lose the information you entered in a box or text field - so avoid unlocking the document until you have completed all of the form fields and then do not re-lock it.

In order to assure readability, MSD prefers that all request forms be typed rather than handwritten.

Submit the form according to the directions on the form. To avoid any delays in reviewing your request, please be sure to complete the request form and provide all of the requested information and documents.

If you have any questions about the request form or MSD's charitable contribution program and practices, send an email to MSD's Charitable Contributions Manager at MSDCharitableContributions@medtronic.com. The current Charitable Contributions Manager's name and phone number are available at the Charitable Contributions home page in the Charitable Contributions Manager section..

Please read the rest of this page before completing a request form to make sure you have all of the information that you need before you complete the form.

Download Charitable Mission Product Charitable Contribution Request Form

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Patient Assistance Product Contributions and Request Form
Some patients receiving care in the U.S. may benefit from Medtronic Sofamor Danek products, but do not have the ability to pay for the product, typically because they are uninsured and do not have Medicare or Medicaid coverage. In such cases, Customers may ask MSD for the product free of charge.

To download a Word version of the Patient Assistance Product Charitable Contribution Request Form, click on the link at the bottom of this section.

MSD's charitable contribution request forms are formatted with MicroSoft's form tool. To complete the request form:

• Move to each field that needs to be completed by using the Tab button or a moving your curser to the next field.
• If the field is a box, then just click on the appropriate box to place an "x" in the box.
• If the field is a gray text area (it is empty white space in a printed version of the form), simply start typing in the requested information.
• If you need to unlock the form to add information that does not have a box or text field: (1) select "View" on the top menu bar, (2) select "Toolbars", (3) select the "Forms" toolbar. Once the toolbar is added, click on the icon that looks like a padlock so it is no longer highlighted. You can then type anywhere on this document. If you click on the padlock again, you may lose the information you entered in a box or text field - so avoid unlocking the document until you have completed all of the form fields and then do not re-lock it.

In order to assure readability, MSD prefers that all request forms be typed rather than handwritten.

Submit the form according to the directions on the form. To avoid any delays in reviewing your request, please be sure to complete the request form and provide all of the requested information and documents.

If you have any questions about the request form or MSD's charitable contribution program and practices, send an email to MSD's Charitable Contributions Manager at MSDCharitableContributions@medtronic.com. The current Charitable Contributions Manager's name and phone number are available at the Charitable Contributions home page in the Charitable Contributions Manager section.

Please read the rest of this page before completing a request form to make sure you have all of the information that you need before you complete the form.

Download Patient Assistance Product Charitable Contribution Request Form

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Product Charitable Contribution Criteria
In addition to the criteria that apply to all Customer-Based Charitable Contributions, a product charitable contribution request must also satisfy the following additional criteria:

1. The patient's physician(s) and hospital or other facilities will not bill the patient, Medicare, Medicaid, or any other person or third party payor for the cost of any of the health care services for which any contributed MSD Products will be used or for the contributed MSD Products
2. The lead physician and/or facility does not have a history of failing to return unused MSD Products from prior product contributions

If the issue is that the hospital feels it is not being adequately reimbursed by Medicare, Medicaid, or insurers for the cost of the surgery and the products, it may be that the claims are not properly coded and billed. MSD's Healthcare Economic Services may be able to help. If you are a Customer, ask your sales representative about whether Healthcare Economic Services can help you.

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Sales Personnel Required to Prepare Product Request Lists
Generally, Sales Personnel are prohibited from assisting Customers in any way in completing or submitting a charitable contribution request form. There is an exception for product charitable requests because sales representatives are the people best able to complete the product request list. Customers do not have the type of information we need, such as set types and item numbers.

Consequently, sales representatives are required to complete the product request lists that are part of the Charitable Mission and Patient Assistance Product Charitable Contribution Request Forms. Customers should always let their sales representatives know if they plan to submit a product contribution request so their sales representative can help them with the product request list. If a sales representative becomes aware that a Customer plans to submit a product contribution request, he should contact the Customer to get the information he needs to complete the product request list.

Sales Personnel may not help Customers complete any other part of the request forms. If Customers have questions about any other parts of the request form, they should contact the people identified on the request form or this website.

Sales representatives are also permitted to :

• Provide any assistance requested by MSD's Charitable Contributions Manager once a product contribution has been approved.
• Provide any standard and typical product support once the contribution has been approved, including accompanying the Customer to the charitable mission location.

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Product Contributions Involve Special and Unique Challenges
Reviewing and approving requests for product contributions, especially for foreign charitable missions to provide health care to indigent patients, are particularly challenging.

• There is a significant amount of information that is necessary and several people are involved in the review and approval process.
• We need to determine what products are available for contribution and work with staff to organize any products that are contributed.
• There can be issues related to shipping and customs.
• It is also often necessary for MSD sales representatives to participate in order to provide the same type of product support they provide when MSD products are used in the U.S. However, the sales representatives may not participate in or try to influence the decision of whether to make the product contribution.

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Limited Availability of Biologic Products for Contributions
MSD's biologic products may not be available for charitable missions because:

1. They are not approved for use in the charitable mission country, or
2. We cannot guarantee the shipping and storage requirements, such as temperature control, can be satisfied - often because the receiving hospital or facility cannot satisfy the storage requirements.

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China Charitable Mission Issues
Charitable missions are supplied primarily using U.S.-based loaner sets. Chinese law prohibits MSD from sending U.S.-based loaner sets into China. Consequently, most products for charitable missions in China are supplied by MSD's China distributor. Our China distributor does not maintain the amount or type of inventory maintained in the U.S. If we have enough notice, we may also be able to order new implants (typically not instruments) for use during a mission in China.

As a result, the lead physician and MSD sales representative need to realize that the products available for the mission may be more limited - both in type and sizes -- than is typically available in the U.S. or during charitable missions to other countries. There may also need to be several interactions between the sales representative and MSD's China staff before the mission to understand what is and is not available for the mission.

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Business Conduct Standard Brochure
MSD's Compliance office has a "Charitable Contributions Program" brochure that provides answers to common questions people have.

To order the brochure, you need access to MySpineTools.com. If you do not have access, you can ask your local MSD sales representative for the brochure or send an email to MSDCharitableContributions@medtronic.com and ask for the brochure

If you have access to MySpineTools.com, the brochure can be ordered on MySpineTools.com by selecting "Resources" from the top navigation bar and then, from the Overview page, select "Click here to order available literature and video for customer use." The brochures are under the Sales Division category. The Item # for the brochure is LITCCBR4.

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