100X Colic Surgery Coverage

Program Compliance Affidavit

For the Attending Veterinarian. This affidavit is part of a claim for Surgical Reimbursement under the 100X Equine Colic Surgery Coverage Program. Please complete all fields accurately, based on the veterinary medical records available to you.

Deadline: submit within 14 calendar days of the horse’s discharge from the veterinary surgical facility. Submission does not constitute approval of Surgical Reimbursement; all claims are reviewed under the Program Terms & Conditions.

1Horse & owner information

So this affidavit can be matched to the correct claim.

Horse’s registered name

Owner / customer full name

Program confirmation number

Claim number, if provided

2Attending Veterinarian information

The Attending Veterinarian must be licensed in the United States.

Attending Veterinarian full name

Veterinary practice / hospital

Veterinary license number

State of licensure

Phone number

Email address

3Colic incident & surgery information

Date of colic incident

Date admitted to surgical facility

Date of surgery

Date of discharge

Veterinary surgical facility

Veterinarian performing surgery

State of licensure of veterinarian performing surgery

Primary diagnosis / cause of colic, if known

Surgical procedure performed

Was the surgical procedure an emergency, non-elective surgery involving the horse’s digestive tract?

Was the horse euthanized during surgery based on the operating veterinarian’s medical judgment?

Please briefly explain the circumstances surrounding the decision to euthanize the horse during surgery.

4Annual wellness compliance

The applicable wellness period is the twelve (12) months prior to the date of the colic incident. Please answer based on the veterinary medical records available to you.

Physical examination

Did the horse receive at least one (1) physical examination by the Attending Veterinarian during the applicable twelve (12)-month period?

To the best of your knowledge and based on the medical records available to you, were the Attending Veterinarian’s recommendations resulting from the examination followed?

Dental care

Did the horse receive at least one (1) dental examination by the Attending Veterinarian during the applicable twelve (12)-month period?

Was dental treatment recommended as a result of the examination and, if so, was the recommended treatment administered?

Vaccinations

Did the horse receive annual core vaccinations administered by the Attending Veterinarian, as well as any additional vaccinations recommended by the Attending Veterinarian?

Deworming program

Did the horse participate in a deworming program directed by the Attending Veterinarian during the applicable twelve (12)-month period?

Did the deworming program include at least two (2) deworming administrations during the applicable twelve (12)-month period?

Did the deworming program include at least one (1) fecal egg count test during the applicable twelve (12)-month period?

Timing of wellness requirements

Were the wellness items relied upon above performed or administered outside of the colic incident or colic surgery and more than seventy-two (72) hours prior to the onset of the colic incident or colic surgery?

5Veterinarian certification

I certify that I am a veterinarian licensed in the United States and that, to the best of my knowledge, the information provided in this Program Compliance Affidavit is true and accurate and is supported by the veterinary medical records available to me.

I understand that this affidavit is being submitted in connection with a request for Surgical Reimbursement under the 100X Equine Colic Surgery Coverage Program and that 100X Equine may request supporting veterinary medical records or additional information as part of its review.

I understand that completion and submission of this affidavit does not constitute approval of Surgical Reimbursement. Eligibility and reimbursement determinations are made by 100X Equine in accordance with the 100X Equine Colic Surgery Coverage Program Terms & Conditions.

I certify that the information provided in this Program Compliance Affidavit is true and accurate to the best of my knowledge and electronically sign this affidavit.

Attending Veterinarian full legal name

Typing your full legal name constitutes your electronic signature on this Program Compliance Affidavit. The date of certification is recorded automatically at submission.

Questions? Call 1-800-677-3574 or email Support@100XEquine.com.

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Affidavit submitted.

Thank you. Your Program Compliance Affidavit has been submitted to 100X Equine and will be reviewed as part of the applicable Surgical Reimbursement claim.

Submission of this affidavit does not constitute approval of Surgical Reimbursement. 100X Equine may contact you at if additional information or supporting veterinary medical records are required.