logo

Apheresis donors needed!

Apheresis donors (Platelets, Plasma) are needed IMMEDIATELY for continued patient care. Learn more about the donation process.

Please complete all information requested on the form. Missing information may delay the process of the claim. If you have any questions, contact Patient Claims at (504)592-1533
<br> <br>
The Blood Center will review the form, then process the claim for payment. Payments will be made directly to the patient and will be generated on a monthly basis. Claims must be submitted within 6 months from the date of blood component usage.
<br><br>
Alternatively, you can also print out and submit a paper form: <a href="https://cms.thebloodcenter.org/sites/default/files/2020-08/BloodReplacementClaimForm.pdf">Click here to download the form.</a>


<iframe
id="JotFormIFrame-211055351778052"
title="BLOOD REPLACEMENT CLAIM FORM"
onload="window.parent.scrollTo(0,0)"
allowtransparency="true"
allowfullscreen="true"
allow="geolocation; microphone; camera"
src="https://hipaa.jotform.com/211055351778052"
frameborder="0"
style="
min-width: 100%;
height:539px;
border:none;
resize: both;
overflow: auto;"
scrolling="yes"
>
</iframe>
<script type="text/javascript">
var ifr = document.getElementById("JotFormIFrame-211055351778052");
if (ifr) {
var src = ifr.src;
var iframeParams = [];
if (window.location.href && window.location.href.indexOf("?") > -1) {
iframeParams = iframeParams.concat(window.location.href.substr(window.location.href.indexOf("?") + 1).split('&'));
}
if (src && src.indexOf("?") > -1) {
iframeParams = iframeParams.concat(src.substr(src.indexOf("?") + 1).split("&"));
src = src.substr(0, src.indexOf("?"))
}
iframeParams.push("isIframeEmbed=1");
ifr.src = src + "?" + iframeParams.join('&');
}
window.handleIFrameMessage = function(e) {
if (typeof e.data === 'object') { return; }
var args = e.data.split(":");
if (args.length > 2) { iframe = document.getElementById("JotFormIFrame-" + args[(args.length - 1)]); } else { iframe = document.getElementById("JotFormIFrame"); }
if (!iframe) { return; }
switch (args[0]) {
case "scrollIntoView":
iframe.scrollIntoView();
break;
case "setHeight":
iframe.style.height = args[1] + "px";
break;
case "collapseErrorPage":
if (iframe.clientHeight > window.innerHeight) {
iframe.style.height = window.innerHeight + "px";
}
break;
case "reloadPage":
window.location.reload();
break;
case "loadScript":
if( !window.isPermitted(e.origin, ['jotform.com', 'jotform.pro']) ) { break; }
var src = args[1];
if (args.length > 3) {
src = args[1] + ':' + args[2];
}
var script = document.createElement('script');
script.src = src;
script.type = 'text/javascript';
document.body.appendChild(script);
break;
case "exitFullscreen":
if (window.document.exitFullscreen) window.document.exitFullscreen();
else if (window.document.mozCancelFullScreen) window.document.mozCancelFullScreen();
else if (window.document.mozCancelFullscreen) window.document.mozCancelFullScreen();
else if (window.document.webkitExitFullscreen) window.document.webkitExitFullscreen();
else if (window.document.msExitFullscreen) window.document.msExitFullscreen();
break;
}
var isJotForm = (e.origin.indexOf("jotform") > -1) ? true : false;
if(isJotForm && "contentWindow" in iframe && "postMessage" in iframe.contentWindow) {
var urls = {"docurl":encodeURIComponent(document.URL),"referrer":encodeURIComponent(document.referrer)};
iframe.contentWindow.postMessage(JSON.stringify({"type":"urls","value":urls}), "*");
}
};
window.isPermitted = function(originUrl, whitelisted_domains) {
var url = document.createElement('a');
url.href = originUrl;
var hostname = url.hostname;
var result = false;
if( typeof hostname !== 'undefined' ) {
whitelisted_domains.forEach(function(element) {
if( hostname.slice((-1 * element.length - 1)) === '.'.concat(element) || hostname === element ) {
result = true;
}
});
return result;
}
};
if (window.addEventListener) {
window.addEventListener("message", handleIFrameMessage, false);
} else if (window.attachEvent) {
window.attachEvent("onmessage", handleIFrameMessage);
}
</script>