*RESHAPE BALLOON REBATE PROGRAM TERMS AND CONDITIONS
Step 1: Patient registers on ReShape Balloon™ Patient Portal or Retrofit Patient Portal and records initial weight
Step 2: At the time of balloon placement, Physician office completes, signs and faxes or mails the rebate form to ReShape Lifesciences™
Step 3: At the three (3), six (6), nine (9) and twelve (12) month check points the Physician office completes, signs and faxes or mails rebate form to ReShape Lifesciences within 30 days of each checkpoint
Step 4: Qualified patients will receive rebates within eight weeks of each rebate form receipt
“ReShape Rewards Program” is a rebate program that works by providing you (the patient) up to $1,200 in mail-in rebates from ReShape Lifesciences for your first balloon insertion by your treating Physician. All qualifying, eligible patients losing 10% of their total body weight at the third (3) month check point will be eligible for a $300 mail-in rebate. Patients losing 15% of their total body weight at the sixth (6) month check point will be eligible for an additional $300 mail-in
rebate ($600 total rebate if combined with previous rebate). Patients losing 18% of their total body weight at the ninth (9) month check point will be eligible for an additional $300 mail-in rebate ($900 total rebate if combined with all previous rebates). Patients losing 20% or more of their total body weight at the twelfth (12) month check point will be eligible for an additional $300 mail-in rebate ($1,200 total rebate if combined with all previous rebates). To qualify for this offer,
you and your Physician must properly complete a rebate form following each applicable weigh-in and register your weight on the ReShape Balloon Patient Portal or Retrofit Patient Portal. You must further agree to all stated disclosures and waivers. The ReShape Balloon used in your treatment must be purchased legally in the U.S. and administered in accordance with a valid prescription by a licensed Physician. Percent total body weight loss must meet criteria by the third, sixth, ninth and
twelfth check points – if you (the patient) are not able to meet the check point criteria you are still eligible for the next rebate if you qualify. For eligibility, the balloon procedure must be scheduled before September 28, 2018. You must provide the rebate forms to your treating Physician, and the forms must be completed, signed and faxed or mailed within 30 days of each rebate check point. Total percent weight lost will be determined, by your Physician, at the three, six, nine and
twelve month check points and entered, by your Physician into the form, and then confirmed via the portal. Qualified patients will receive rebates within eight (8) weeks of qualifying event. If you have questions about this offer, please call toll free 1-844-355-5974. Rebate requests postmarked or sent by facsimile after September 28, 2018, will not be considered.
You must be 22 years of age or older to be eligible. Patient, Pharmacist, and prescriber agree not to seek reimbursement from any third party for all or any part of the benefit received by the patient through the offer. You are eligible for this offer only if you paid for your entire treatment yourself and if no part of your treatment was covered by insurance or another third-party payer. You are not eligible for this offer if your private insurance, HMO, or other health benefit program
paid for all or part of your treatment. If any form of reimbursement is sought from a third-party, you will be required to disclose the value of this rebate to that party or entity. This offer is available only to qualifying patients, excluding claims from ReShape Lifesciences employees and their spouses. This offer is non-transferable. No substitutions are permitted. No membership fees are associated with this offer. Offer valid only in the U.S., from participating Physicians. Void where
prohibited by law, taxed, or restricted. To locate participating Physicians, visit reshapeready.com or call 1-844-355-5974.
This offer is limited to one redemption per person and cannot be combined with any other ReShape Lifesciences offer or promotion. No other purchase is necessary. This rebate is not insurance. By submitting a rebate request, you agree to all of the terms and conditions of this offer. ReShape Lifesciences reserves the right to cancel or modify this offer without notice. All rebate requests become the property of ReShape Lifesciences and will not be returned. ReShape Lifesciences assumes no
responsibility for lost, late, damaged, misdirected, misaddressed or incomplete requests that fail to be properly delivered for any reason. Rebate checks will be issued in U.S. dollars only. Rebate checks are void if not cashed or used within 180 days. It is illegal to sell, purchase, trade, or counterfeit, or offer to sell, purchase, trade, or counterfeit the rebate check.
Indication and Important Safety Information:
The ReShape Balloon™ System is indicated for weight reduction when used in conjunction with diet and exercise, in obese patients with a Body Mass Index (BMI) of 30 – 40 kg/m2 and one or more obesity-related comorbid conditions. It is indicated for use in adult patients who have failed weight reduction with diet and exercise alone. The ReShape Balloon System is not recommended for patients with conditions that may increase the risk of poor results (e.g., prior gastrointestinal surgery with
sequelae, prior open or laparoscopic bariatric surgery, inflammatory diseases of the GI tract, potential upper GI bleeding), who are unwilling to participate in an established medically-supervised diet and behavior modification program, who have alcohol or drug addictions, who receive daily prescribed treatment with aspirin, anti-inflammatory agents, anticoagulants or other gastric irritants, or who currently are or may be pregnant or breast-feeding. The maximum placement period for the
ReShape Balloon is 6 months. The risk of intragastric balloon deflation and intestinal obstruction (and therefore possible complications related to intestinal obstruction) is significantly higher when balloons are left in place longer than 6 months. The presence of blue-green urine or sudden loss of satiety, increased hunger and/or weight gain may be a sign of balloon deflation. Intestinal obstructions have been reported due to deflated balloons passing into the intestines and have
required surgical removal. Death due to intestinal obstruction is possible. Patients experiencing symptoms of an intestinal obstruction (e.g., acute onset of abdominal pain, nausea or vomiting) should seek immediate care. Failure of patients to take prescribed daily proton-pump inhibitor medication increases the risk of gastric ulceration or perforation. Placement of the ReShape Balloon requires an endoscopic procedure with sedation. Potential risks associated with an endoscopic procedure
and sedation include adverse reaction to sedation (headache, muscle pain, nausea), anaphylaxis, cardiac arrest, death, hypoxia, myocardial infarction, gastric and esophageal perforation, infection, pneumonia, and respiratory distress. Risks that have been associated with treatment with the ReShape Balloon include death, acute pancreatitis, esophageal perforation, gastric perforation, ulceration, significant gastric bleeding, gastric outlet obstruction, aspiration pneumonia, bowel
obstruction, balloon hyperinflation, need for blood transfusions, emergency endoscopic therapeutic intervention, abdominal pain, abdominal spasms, nausea, vomiting, bloating, belching, heartburn, dysphagia, dehydration, and sore throat. These complications may be severe enough to require early removal of the ReShape Balloon. Although the ReShape Balloon design provides an anti-migration feature, there is the potential risk of device migration and intestinal obstruction. The risk of
intestinal obstruction is increased if the device is not removed after 6 months. If intestinal migration occurs, surgical or endoscopic removal may be required. (06-04-18) For full safety information please visit reshapeready.com
RESHAPE, RESHAPE LIFESCIENCES, ReShape Balloon™, and the ReShape Balloon logo are trademarks of ReShape Lifesciences, Inc.
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