Application Form Instructions
|
|
|
- Warren Chapman
- 6 years ago
- Views:
Transcription
1 The Lilly Cares Foundation, Inc., a private operating foundation, offers the Lilly Cares patient assistance program to help qualifying people get selected Lilly medications. What products are included? Group A: For patients who have Medicare Part D OR no insurance. Cialis (tadalafil) Cymbalta (duloxetine delayed-release capsules) Effient (prasugrel) Evista (raloxifene hydrochloride) Forteo (teriparatide [rdna origin] injection) Glucagon (glucagon for injection[rdna origin]) Humalog (insulin lispro injection) Humulin (human insulin[rdna origin]) Group B: For patients who have Medicare Part D OR no insurance OR those whose insurance does not cover the Lilly drug. Humatrope (somatropin [rdna origin] for injection) Application Form Instructions Group C: For patients who have no insurance OR those whose insurance does not cover the Lilly drug. Lilly Oncology products provided free of charge through the Lilly PatientOne Patient Assistance Program are provided by the Lilly Cares Foundation, an independent non-profit 501(c)(3) organization that helps eligible patients obtain certain products. PatientOne collects information on behalf of the Lilly Cares foundation for that purpose. For information, call Who qualifies for this program? To qualify, you must meet ALL of the requirements listed below: My doctor has prescribed a Lilly drug for me. I am a permanent, legal resident of the United States. Prozac (fluoxetine) ReoPro (abciximab) Strattera (atomoxetine) Symbyax (olanzapine and fluoxetine) Trulicity (dulaglutide) Zyprexa /Zyprexa Intramuscular/Zyprexa Relprevv /Zyprexa Zydis (olanzapine) If I am a Medicare Part D patient (except Forteo patients), I have spent $1,100 on medicine this calendar year. I am NOT enrolled in or eligible for Medicaid or Veteran s Administration Benefits. My doctor prescribed a Lilly drug in Group A and I have Medicare Part D OR no insurance. My doctor prescribed a Lilly drug in Group B and I have Medicare Part D OR no insurance OR my insurance does not cover the Lilly drug. Humatrope Patients - Must have a No Funding Letter from Humatrope Direct Connect which states that I have no other way to pay for my Humatrope therapy. Contact Humatrope Direct Connect at 1-84Humatrope ( ) if you need this letter. Medicaid or Veteran s Administration Benefits may qualify. If you have questions about qualifying and applying, please call us at
2 Application Form Instructions - Continued Who qualifies for this program? - Continued My household income is under the Annual Income Limit listed below: Annual Income Limit *If you live in Alaska, Hawaii, or D.C., please Number of Persons in Your Household contact us for adjusted Annual Income Limits Group A Products Group B Products 1 $35,640 $59,400 2 $48,060 $80,100 3 $60,480 $100,800 4 $72,900 $121,500 5 $85,320 $142,200 6 $97,740 $162,900 *Note: These income limits are 300% and 500% of 2016 Federal Poverty Guidelines. You may also visit for information on Federal/Poverty Level. Federal Poverty Guidelines may change yearly. How do I apply? To apply, complete the following 4 steps: 1. Complete and return the Patient Section (page 4) and sign the Patient Certification (pages 5-6). 2. Have your doctor complete and return the Doctor Section, sign the Doctor Confirmations and Agreements, and send a prescription for your medicine (page 7). 3. If you have Medicare, attach a copy of the front of your Medicare Part D card. Attach a copy of your Low Income Subsidy denial or rejection letter if this applies to you. 4. Select and copy appropriate proof-of-income documents. Keep copies for your records. 5. Fax or mail the application form, prescription, copies of proof-of-income and copy of Medicare Part D card (if this applies to you) to Lilly Cares. Mailing address and fax number are at the top of this page. What happens next? When we receive your application, we will review it to see if you qualify for Lilly Cares. If you are a Medicare Part D patient: 1. You will be enrolled until the end of the calendar year and must apply again upon reaching your out-of-pocket pharmacy spend (except Forteo) for the next calendar year. 2. You will pick up your medication from your doctor in 3-4 weeks. Forteo and Humatrope generally require home delivery due to medication handling. Patient will be contacted to schedule home delivery starting May, If you are under the age of 65 and NOT a Medicare Part D patient: 1. You will be enrolled for 12 months. After 12 months, you must apply again. 2. You will pick up your medication from your doctor in 3-4 weeks. Forteo and Humatrope generally require home delivery due to medication handling. Patient will be contacted to schedule home delivery starting May If you do NOT qualify, we will send a notice to you and your doctor. If you have questions about qualifying and applying, please call us at
3 This page intentionally left blank 3
4 Patient Section Patient Name:(Last) (First) (MI) Address: City: State: Zip Date of Birth: / / Month Day Year Home Phone ( ) - Cell Phone ( ) - Patient Income Information Number of family members living in your household: Total Gross Household Income (before deductions): /yearly 1. Proof of income send copies only, no originals Send at least 1 document that shows that you have a low income, or no income such as documents listed below: Copy of last year s Federal Income Tax Return Copy of current pay stubs or earnings statements Copy of Social Security Income Yearly Benefit Statement Copy of W-2 or 1099 Form Copy of Unemployment Benefit Statement Copy of Statements of interest, dividends, or other income 2. Additional Proof of Pharmacy Spend Required for Medicare Patients (except Forteo patients): Send proof that you have spent $1,100 (except Forteo) on medicine this year. This can be an explanation of benefits or summary from your pharmacy where you get your medications filled. Text Message If your application is approved we can send you a text message. The text message is optional. You can participate in Lilly Cares without signing up for the text message. When you sign up for the text message, you must agree to the following conditions: Lilly will send only one message. It will be an autodialed, pre-recorded message. (Standard text message and data rates apply.) Be aware that anyone who can open your phone might see your text message. The text message is NOT a reminder. You are responsible for taking your medication as prescribed. Do NOT report product complaints or adverse events (like side effects) by text message. To report these; please call the Lilly Answers Center at LillyRx ( ). To receive a text message, you must provide your Cell Phone Number If you do not know which documents to send, you can call Lilly Cares at Please read and continue on page 5: 4
5 Patient Certification (Agreement) I certify (agree) that the following statements are true: I am a legal, permanent resident of the United States. I am NOT enrolled in or eligible for Medicaid or Veteran s Administration. Humatrope patients may be eligible. If I am a Medicare patient (except Forteo patients), I have spent $1,100 on medications this year. My doctor prescribed a Lilly drug in Group A and I have Medicare Part D OR no insurance. My doctor prescribed a Lilly drug in Group B and I have Medicare Part D OR no insurance OR my insurance does not cover the Lilly drug. I consent to the sharing, use, and receipt of information about me, as described below: To run Lilly Cares, Lilly needs some information about you. When you sign below, you understand and you are authorizing Lilly to share, use and disclose your information, and you are authorizing any pharmacy and or health care provider who is in possession of your health information to share with Lilly information about you, including health information, that will be used to operate and administer the Lilly Cares Program, as stated below. Lilly refers to Lilly, Lilly Cares, and its vendors and business partners contracted to be the Program administrator of Lilly Cares. Lilly may receive, share, and use the following information: Information in this application. Information about my medical conditions, treatment, current and future medicines, and insurance information. Other information Lilly may obtain to operate the Lilly Cares Program. Lilly may share my information with my health care providers and pharmacists. My health care providers and pharmacists may share my information with Lilly. Lilly may share my information with the Centers for Medicare and Medicaid Services ( CMS ) and/or my Medicare Part D Plan Administrator. This will be consistent with the terms of any Data Sharing Agreement agreed upon by Lilly and CMS or my Medicare Part D Plan. Lilly may share my information for the following purposes: To review my application and to contact me or my health care provider, if necessary, for that review. To help operate the Lilly Cares Program and Lilly s internal purposes involving other patient assistance and charitable programs. To my pharmacies and health care providers relating to my participation in Lilly Cares, including personal information and information about my prescription drugs. If you do not know which documents to send, you can call Lilly Cares at Please read and sign the next page: 5
6 Patient Certification (Agreement) - Continued By my signature below, I also agree to the following: If I am NOT a Medicare Part D patient, I understand that my authorization to release my Protected Health Information (PHI) enables a health care provider relying on this authorization to release my PHI to Lilly for one year from the date it is signed, and then I need to apply again to Lilly Cares. If I am a Medicare Part D participant, I understand that my authorization to release my PHI enables a health care provider relying on this authorization to release my PHI to Lilly for the remainder of this calendar year that it is signed, and then I need to apply again to Lilly Cares. I understand that if my information is shared in this manner, federal and state privacy laws may no longer protect my PHI and may not prohibit its further disclosure; however, Lilly has committed to use and disclose my PHI only as stated in this form. I understand if I do not sign or refuse to sign this form, I will not be eligible for Lilly Cares. I understand that I can cancel my consent any time by sending a written notice to Lilly Cares at the address on this application. If I cancel my consent, I will no longer qualify for Lilly Cares. My health care providers will no longer share my PHI with Lilly after the date that Lilly receives and processes my cancellation letter, but this will not affect information or disclosures shared before that time. Additionally, once my cancellation is received and processed by Lilly, my participation in the program will be terminated and after my participation is terminated, Lilly will only maintain and use my information for legal and regulatory purposes. I agree to follow the rules and conditions of the Lilly Cares Program. I have been provided a copy of this authorization. I understand that Lilly Cares will decide if I qualify for this program. I understand that my application might not be approved. I will not submit any claim for reimbursement to any third party insurer for any product provided to me under the Lilly Cares Program. If I am in Medicare, I will not claim any true-out-of-pocket-cost ( TROOP ) from my Medicare Part D Plan for the value of the product given to me under Lilly Cares. If I am in Medicare, I understand that it is my responsibility to let my Medicare Part D Plan know about my enrollment in the Lilly Cares Program. I understand the Lilly Cares Program may change or end at any time without advance notice. I understand and agree that if Lilly asks, I will provide documentation that proves the information I have certified in this application is true, correct, and complete. I understand that the Lilly Cares Foundation 501(c)(3) does not charge a fee for participation in the Lilly Cares program. Lilly is not affiliated with third parties who charge a fee for help with enrollment or medication refills. I am not required to use a third party who charges a fee to help with my enrollment, and if I use a third party who charges a fee to help with my enrollment or refills of my medicine, this money is not paid to the Lilly Cares Foundation 501(c)(3). Patient or Legal Guardian Signature: Date: Signature Required 6
7 Name of doctor/prescriber: (circle: M.D. D.O. N.P. P.A.) Mailing Address: City: State: Zip: Suite Number: Shipping Address for medications: City: State: Zip: Suite Number: (Note: We must ship medication to the prescribing provider. We cannot ship to a PO Box.) Phone: ( ) - Fax: ( ) - State License # Expiration Date: DEA # Expiration Date: (Only for requests of controlled substances) Prescription and Refill Information: Completion of this section is OPTIONAL for the Doctor/Prescriber, PROVIDED an actual prescription is submitted with the application. Forteo and Humatrope REQUIRE an actual prescription, with the doctor/prescriber signature. Patient Name: Product Requested: Dosage: (If prescribing insulin indicate max number of units/day) Sig: Quantity: Doctor/Prescriber s Confirmations and Agreements: Lilly Cares agrees, to the extent consistent with its exempt purposes, qualified under Section 170(e)(3) of the Internal Revenue Code of 1986, as amended (the Code ), and authorized by Lilly Cares policies, to provide medicines, prescription drugs, and other pharmaceutical products, medical supplies, and property (the Medications ) to the prescriber (the health care provider ) for the sole purpose of caring for the ill, needy, indigent, and/or infants in the United States (the Qualifying Patients ). By signing below, I (the Prescriber) agree to the following terms and conditions: I will accept the Medication from Lilly Cares (except Forteo and Humatrope which may be dispensed to the patient home) and deliver the Medication only to the qualifying Patient named on this form at no charge of any kind. I will not use any of the Medication for any other purpose. This Medication will not be offered for sale, trade, or barter. Doctor Section Medication orders may be written for up to a 1-year supply, subject to program eligibility limits. Up to a 120- day supply is available in each shipment, unless a lesser amount is prescribed or provided per program guidelines. Refills: Lilly Cares Fax Refill form is located on our web site at or can be placed by calling If the prescription is as listed on the original approved application, the refill request will be processed. If any part of the prescription has changed, a completed refill form will be required. * I have made my patient aware that I am releasing their personal health information to Lilly Cares for treatment purposes. I will give Lilly Cares 90 days advance notice if I need to assign this agreement, in full or in part, to another Prescriber. I am licensed to practice and dispense medicine and will comply with and abide by my State Practitioner dispensing laws for authorized prescribers in the state in which I am prescribing, receiving, storing, and dispensing this Medication to the above Patient. Lilly Cares has the right to contact the Patient directly to make sure that the Medication was received. Lilly Cares has the right to revise or terminate the Program at any time. All the Lilly Cares Medications I have ever received and distributed were distributed only to Qualifying Patients. I agree to properly dispose of unused Medication. My signature below attests to my understanding and agreement to the above program requirements. Prescriber Signature: Date: Original Signature Only; No Photocopies or Stamps PP-AP-US-0142 W 4/2016 Lilly USA, LLC ALL RIGHTS RESERVED. 7
Application Form Instructions
Lilly Cares Foundation Patient Assistance Program PO Box 13185 La Jolla, CA 92039 1-800-545-6962 Fax: (844) 431-6650 www.lillycares.com The Lilly Cares Foundation, Inc., a separate nonprofit foundation,
Patient Section. Patient Name: (Last) (First) (MI) Address: City: State: Zip: Date of Birth: / / Month Day Year Home Phone: ( ) - Cell Phone: ( ) -
Lilly Cares Foundation Patient Assistance Program PO Box 13185 La Jolla, CA 92039 1-800-545-6962 Fax: (844) 431-6650 www.lillycares.com Patient Name: (Last) (First) (MI) Address: City: State: Zip: Date
Patient Section All fields are required. Please print clearly and complete all information.
Lilly Cares Foundation Patient Assistance Program PO Box 13185 La Jolla, CA 92039 Phone: 1-800-545-6962 Fax: 1-844-431-6650 www.lillycares.com Patient Section All fields are required. Please print clearly
NeedyMeds
NeedyMeds www.needymeds.org Find help with the cost of medicine Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need.
Number of Persons in your Household 1 $60,300 4 $123,000 2 $81,200 5 $143,900 3 $102,100 6 $164,800
The Lilly Cares Foundation, Inc. ("Lilly Cares"), a nonprofit organization, offers a patient assistance program to assist qualifying patients in obtaining certain Lilly medications at no cost. This enrollment
NeedyMeds
NeedyMeds www.needymeds.org Find help with the cost of medicine Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need.
Pfizer Patient Assistance Program: Instructions for Group D Enrollment Form
Pfizer Patient Assistance Program: Instructions for Group D Enrollment Form This enrollment form is for patients who would like to apply to receive Lyrica (pregabalin) or Lyrica CR (pregabalin) extended
Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need.
Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need. Did you know that NeedyMeds has thousands of other free resources?
Pfizer Patient Assistance Program
Pfizer Patient Assistance Program Application for Patients This application form is for patients who would like to apply to receive INFLECTRA (infliximab-dyyb) for Injection, NIVESTYM (filgrastim-aafi)
Pfizer Patient Assistance & Insurance Support Programs: Enrollment Form for Group B Medicines
Pfizer Patient Assistance & Insurance Support Programs: Enrollment Form for Group B Medicines This enrollment form is for patients who would like to apply to receive any of the Group B medicines found
NeedyMeds
NeedyMeds www.needymeds.org Find help with the cost of medicine Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need.
NOVARTIS ONCOLOGY SERVICE REQUEST
Patient First Name Patient Last Name Patient of Birth NOVARTIS ONCOLOGY SERVICE REQUEST FORM FOR PATIENT SUPPORT For more information, please call 1-800-282-7630 from 9:00 am to 8:00 pm ET, Monday through
Pfizer Patient Assistance Program: Instructions for Group A Enrollment Form
Pfizer Patient Assistance Program: Instructions for Group A Enrollment Form This enrollment form is for patients who would like to apply to receive any of the Group A medicines found below for free through
NOVARTIS ONCOLOGY SERVICE REQUEST
NOVARTIS ONCOLOGY SERVICE REQUEST FORM (CONT) Patient First Name Patient Last Name Patient of Birth NOVARTIS ONCOLOGY SERVICE REQUEST 5. PRESCRIPTION INFORMATION (TO BE COMPLETED BY PRESCRIBER) FORM FOR
Bayer Patient Assistance Program
Program Guidelines & Application Form PROGRAM GUIDELINES The Bayer Patient Assistance Program provides medication (listed below) for those in need, who have no prescription drug coverage and limited financial
PO Box , Charlotte, NC Phone: (877) Fax: (877)
To apply for help in affording your prescription for Latuda (lurasidone HCl) tablets, please mail or fax a completed application to Sunovion Support Prescription Assistance Program ( Program ), PO Box
Name: Date of Birth: Phone: ( ) Gender: Mailing Address: City: State: Zip: Social Security Number:
To apply for help in affording your Sunovion prescription, please mail or fax a completed application to: Sunovion Support Prescription Assistance Program ( Program ) PO Box 220285, Charlotte, NC 28222-0285
- Cardiac Catherization - Cardiac Angioplasty - Cardiac Bypass - MUGA - CT Scan
Thank you for making an appointment with our office. We look forward to meeting you. Please help us to prepare for your appointment by gathering the information we will need to make the most of your time
FOREST PHARMACEUTICALS, INC. Patient Assistance Program Shoreline Drive Earth City, MO (800)
FOREST PHARMACEUTICALS, INC. Patient Assistance Program 13645 Shoreline Drive Earth City, MO 63045-1241 (800) 851-0758 FPI PATIENT ASSISTANCE PROGRAM The Forest Pharmaceuticals, Inc. (FPI), Patient Assistance
Payment: We are permitted to use and disclose your health information to receive payment for our services. For example, we may:
Your Rx Pharmacy Notice of our privacy practices THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Date of Birth: Phone: ( ) Gender: M F. City: State: Zip:
To apply for help in affording your Seebri Neohaler (glycopyrrolate) Inhalation Powder prescription, please mail completed application to: Sunovion Support Prescription Assistance Program ( Program ) PO
1. A. Prescription medication must be in an original container/vial issued by a pharmacy that indicates the following information:
6003 1 School Administered Medication It is the policy of the Duncan Board of Education that if a student is required to take either prescription medication or non prescription/over the counter medication
10111 Richmond Avenue, Suite 400, Houston, Texas (713) / (866) (Toll Free) / (713) (Fax)
Application Date: \ \ Date Available: \ \ Provider s Name: O MD O DO O PA O NP SS # : City: State: Zip: Home Phone ( ) Work Phone ( ) Pager ( ) Cell Phone ( ) E-Mail address: Driver s Lic. # Expires: \
Applicable State Licensing Requirements for Combined Federal and Comprehensive HHA Survey
Applicable State Licensing Requirements for Combined Federal and Comprehensive HHA Survey Statute 144A.44 HOME CARE BILL OF RIGHTS Subdivision 1. Statement of rights. A person who receives home care services
THE COUNSELING PLACE ADULT INTAKE FORM Yearly Family Income:
Person to Contact in Case of Emergency Name Relationship Best Contact Number Alternative Contact Number Office Use Only Intake Date Reason for referral Counselor THE COUNSELING PLACE ADULT INTAKE FORM
WELCOME. Payment will be expected at the time of service. Please remember our 24 hour cancellation notice.
WELCOME Those of us at Crossroads Counseling want to thank you for choosing to work with us and we want to make your time with us as productive as possible. In order to expedite the intake process, please
Langston University Returning Athlete Screening Form
Langston University Returning Athlete Screening Form Name: Address: Social Security #: : Phone: Sport: DOB: M / D / Y 1. Have you had any injury since your last athletic screening here? Yes: No: If yes,
Associated Pediatric Dentistry Belleville, Edwardsville, O Fallon, IL
Associated Pediatric Dentistry Belleville, Edwardsville, O Fallon, IL Patient Name: DOB: ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT **You May Refuse to Sign This Consent Acknowledgement**
Crossover Healthcare Ministry Financial Application
Crossover Healthcare Ministry Financial Application Are you PREGNANT? HIV positive? Recently been in the ER or HOSPITAL? If YES, please speak with a staff member immediately. *New Patients We are unfortunately
Lalita Matta, MD Estrela Chaves, NP, CDE
PERSONAL INFORMATION Name of Patient: Maiden Name: Social Security No.: Date of Birth: Home Address: City: State: Zip: Home Phone: Mobile Phone: Work Phone: Email Address: Race/ Ethnicity: Marital Status:
247 CMR: BOARD OF REGISTRATION IN PHARMACY
247 CMR 9.00: CODE OF PROFESSIONAL CONDUCT; PROFESSIONAL STANDARDS FOR REGISTERED PHARMACISTS, PHARMACIES AND PHARMACY DEPART- MENTS Section 9.01: Code of Professional Conduct for Registered Pharmacists,
Pain Management Specialists of Southfield Michigan. Michigan Orthopaedic Institute. Thank you for choosing us for your Pain Management Services.
Cain E. Dimon, M.D. Craig S. McCardell, M.D. Helen Puffenberger, PA C Pain Management Specialists of Southfield Michigan A Division of: South Oakland Anesthesia Associates Providing Services at Michigan
Acknowledgement of Receipt of Notice of Privacy Practices
HIPAA PRIVACY FORM 2 Acknowledgement of Receipt of Notice of Privacy Practices Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good
BioMarin Patient and Physician Support (BPPS) Enrollment Forms for KUVAN
BioMarin Patient and Physician Support (BPPS) Enrollment Forms for KUVAN Instructions for Completing Statement of Medical Necessity (SMN) and Prescription for KUVAN If you need assistance with the attached
Administrative Hospitalwide Policy and Procedure Policy: Charity Care and Financial Assistance Policy Number: Joseph S. Gordy, CEO Flagler Hospital
Administrative Hospitalwide Policy and Procedure Policy: Charity Care and Financial Assistance Policy Number: Joseph S. Gordy, CEO Flagler Hospital Originator: Coordinating Departments: Signature: Chief
Community Outreach Services, Inc Greenbelt Road Suite 206 College Park, MD (301) Fax: (301)
Community Outreach Services, Inc. 6215 Greenbelt Road Suite 206 College Park, MD 20740 (301)345-1459 Fax: (301) 345-1305 Office Policies Form *Office Hours *Times are subject to change. Please contact
1. Applicant Name: (Please check one) [ ]Insured/Patient [ ]Patient s Designee [ ]Provider. 2. Patient Name: 3. Patient Address:
![1. Applicant Name: (Please check one) [ ]Insured/Patient [ ]Patient s Designee [ ]Provider. 2. Patient Name: 3. Patient Address:](/thumbs/81/84583994.jpg "1. Applicant Name: (Please check one) [ ]Insured/Patient [ ]Patient s Designee [ ]Provider. 2. Patient Name: 3. Patient Address:")
NEW YORK STATE EXTERNAL APPEAL APPLICATION New York State Insurance Department, PO Box 7209, Albany NY, 12224-0209 If an HMO or insurer (health plan) denies health care services as not medically necessary,
AMENDMENT TO SENATE BILL 772. AMENDMENT NO.. Amend Senate Bill 772, AS AMENDED, by. replacing everything after the enacting clause with the following:
*LRB00RLC00a* Rep. Cynthia Soto Filed: //0 000SB0ham00 LRB0 0 RLC 00 a AMENDMENT TO SENATE BILL AMENDMENT NO.. Amend Senate Bill, AS AMENDED, by replacing everything after the enacting clause with the
Weber Family Chiropractic PC Patient Right to Request Restrictions on Use and Disclosure of Health Information
Weber Family Chiropractic PC Patient Right to Request Restrictions on Use and Disclosure of Health Information Policy No.: 6 Issue Date: 04/14/03 Revision Date: 10/01/2013 Approvals: Dr. Scott Weber Title:
District of Columbia Prescription Drug Monitoring Program
District of Columbia Prescription Drug Monitoring Program What Our Users Need to Know Health Regulation and Licensing Administration Pharmaceutical Control Division February 28, 2017 1 Mission Statement
Responsible Party Information (Information used for patient balance statements) Responsible Party Another Patient Guarantor Self
Patient Information (Please Print) Dr. Miss Mr. Mrs. Sir Patient s Name (Last) (First) (MI) Previous Name Address Line 1 City, State ZIP Home Phone Cell No. Work Phone Ext. Primary Care Provider (PCP)
Indiana Energy Assistance Program Application Part 1. Personal Information
INSERT AGENCY LOGO 2017-2018 Indiana Energy Assistance Program Application Part 1. Personal Information Your Name Date of Birth First MI Last Social Security Number MM-DD-YYYY Current Home Address: Street
INFORMED CONSENT FOR TREATMENT
INFORMED CONSENT FOR TREATMENT I (name of patient), agree and consent to participate in behavioral health care services offered and provided at/by Children s Respite Care Center, a behavioral health care
Medical History Form
Medical History Form Patient Name of Birth Medical History Do you have or have you had any of the following? Condition Yes No Condition Yes No Condition Yes No ADHD Stroke Menopausal Syndrome Allergies
Chapter 1: Overview of Texas Pharmacy Law 1 Contact Hour (Mandatory)
Chapter 1: Overview of Texas Pharmacy Law 1 Contact Hour (Mandatory) By: Katie Blair, PharmD, RPh Author Disclosure: Katie Blair and Elite Professional Education, LLC do not have any actual or potential
CATHERINE FUND FINANCIAL AID APPLICATION March 2016
GUIDELINES/ QUALIFICATIONS FOR Please read all Guidelines, Policies and Procedures, and Instructions before completing application. You must meet all guidelines for your application to be considered. 1.
PATIENT NOTICE. If you are already taking any of the above medications, your provider may want to talk to you about alternative treatments.
PATIENT NOTICE Our goal at is to provide quality medical care. Because of our concern for your health and well-being, there are certain types of medications we may not be able to prescribe to you. Examples
Texas Administrative Code
RULE 19.1501 Pharmacy Services A licensed-only facility must assist the resident in obtaining routine drugs and biologicals and make emergency drugs readily available, or obtain them under an agreement
Epic Pain Management & Anesthesia Consultants, LLC PO Box 1779, Fort Lee, NJ REGISTRATION FORM
REGISTRATION FORM Name (First) (Middle) (Last) M F Social Security of Birth Age Marital Status Single Married Civil Union Widow/ Widower Home Address City State Zip Code Work Address (Cell) (Home) (Work)
MINNESOTA. Downloaded January 2011
MINNESOTA Downloaded January 2011 4658.1300 MEDICATIONS AND PHARMACY SERVICES; DEFINITIONS. Subpart 1. Controlled substances. "Controlled substances" has the meaning given in Minnesota Statutes, section
I. Purpose. II. Definitions
Financial Assistance Policy and Charity Care Policy EFFECTIVE DATE: 1/01/07 REVISED DATE: 3/01/12 REVISED DATE: 9/26/12 REVISED DATE: 12/26/12 REVISED DATE: 2/20/13 REVISED DATE: 4/1/13 REVISED DATE: 1/15/2014
Pfizer RxPathways Patient Assistance Program: Enrollment Form for Group A Medicines
Pfizer RxPathways Patient Assistance Program: Enrollment Form for Group A Medicines Pfizer RxPathways is Pfizer s prescription assistance program that provides eligible patients with access to their Pfizer
Application Requirements to be considered for Approval:
338 Grapevine Hwy. Hurst, Texas 76054 phone: 817.503.1500 toll-free: 877.203.9111 fax: 817.503.1551 www.mhstx.org Application Requirements to be considered for Approval: Please print your answers using
BioMarin Patient and Physician Support (BPPS) Enrollment Forms. for KUVAN
BioMarin Patient and Physician Support (BPPS) Enrollment Forms for KUVAN Instructions for Completing Statement of Medical Necessity (SMN) and Prescription for KUVAN If you need assistance with the attached
Patient Admission Policy & Financial Agreement
Patient Admission Policy & Financial Agreement Name: Date of Birth: Age: Home Phone: Work: Cell: Address: Email: Social Security Number: Name of Spouse/Parent (if a minor): Emergency Contact: Name: Phone:
SENATE, No STATE OF NEW JERSEY. 216th LEGISLATURE INTRODUCED APRIL 28, 2014
SENATE, No. STATE OF NEW JERSEY th LEGISLATURE INTRODUCED APRIL, 0 Sponsored by: Senator LORETTA WEINBERG District (Bergen) Senator JOSEPH F. VITALE District (Middlesex) Senator JAMES W. HOLZAPFEL District
Eastern Oklahoma Donated Dental Services (E.O.D.D.S.)
Eastern Oklahoma Donated Dental Services (E.O.D.D.S.) Dental Applicant Information E.O.D.D.S. operates on a first come, first serve bases; and you will not receive any notification that you have been approved
Patient Information Form
Patient Information Form Full Name: Date of Birth: / / Gender: M or F SS#: Marital Status: Single Married Widowed Divorced Employment Status: Employed Unemployed Retired Disabled Address: City: State:
2018 Minnesota Vaccines for Children (MnVFC) Program Provider Agreement
2018 Minnesota Vaccines for Children (MnVFC) Program Provider Agreement All sites enrolled in the MnVFC program must submit a signed MnVFC Program Provider Agreement by Nov. 30 each year. We prefer you
LEMTRADA Services Form
For Patients to Complete LEMTRADA Services Form Instructions for healthcare providers enrolling patients in One to One To enroll in One to One Support Services for LEMTRADA (alemtuzumab), you and your
Barbara K. McEntee, Ph.D., PLLC 4815 S. Harvard Ave., Suite 470, Tulsa, Oklahoma 74135 Phone: 918-392-4866 Fax: 918-392-4867 www.barbaramcenteephd.com Thank you for the opportunity to provide psychological
Advancing MN Pharmacy 2016 Advocacy Accomplishments & 2017 Plans
Advancing MN Pharmacy 2016 Advocacy Accomplishments & 2017 Plans Jill Strykowski and Michelle Aytay MPhA Public Affairs Co Chairs, PPAJTF Session Objectives Outline the outcomes from the 2016 Legislative
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I. WHO WE ARE This Notice describes the privacy
Provider Enrollment. August 2016
Provider Enrollment August 2016 Overview Enrollment Requirements Provider Responsibilities Enrollment Process Affiliations Signatures and Supporting Documentation 2 Enrollment Requirements 3 Enrollment
Employment, Training, and Support Services Application
Employment, Training, and Support Services Application PHYSICAL LOCATION: MAILING ADDRESS: 194 ALIMAQ DRIVE 3449 REZANOF DRIVE EAST KODIAK AK 99615 PHONE: (907) 486-9879 FAX: (907) 486-4829 EMAIL: ETSS@KODIAKHEALTHCARE.ORG
Pediatric Dental Specialists
Pediatric Dental Specialists Notice of Privacy Practices This Notice describes how your health information may be used and disclosed and how you can get access to this information. Please review it carefully.
Administration Manual Insulin Pump Program (IPP) Policies and Procedures Version 3.0
c Administration Manual Insulin Pump Program (IPP) Policies and Procedures Version 3.0 Health April 2018 2 Table of Contents SECTION 1: INTRODUCTION... 4 SECTION 2: ROLES AND RESPONSIBILITIES... 5 General
Frequently Asked Questions
1. What is dispensing? Frequently Asked Questions DO I NEED A PERMIT? Dispensing means the procedure which results in the receipt of a prescription drug by a patient. Dispensing includes: a. Interpretation
FAMILY PHARMACEUTICAL SERVICES NOTICE OF PRIVACY PRACTICES effective 9/23/2013
FAMILY PHARMACEUTICAL SERVICES NOTICE OF PRIVACY PRACTICES effective 9/23/2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Participation in the Vaccines for Children Program ALL providers servicing our members between the ages of 0-20 are to register with the Vaccine
Participation in the Vaccines for Children Program ALL providers servicing our members between the ages of 0-20 are to register with the Vaccine for Children Program (VFC) and understand that they are
PATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD
PATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD General Consent for Treatment I have the legal right to consent to medical and surgical treatment because (a) I am the patient
Sample Notice of Privacy Practices 2 of 6 cda.org/practicesupport
Sample Notice of Privacy Practices 2 of 6 cda.org/practicesupport RUSSELL L. CURETON D.D.S. Notice of Privacy Practices This Notice describes how your health information may be used and disclosed and how
LIBERTY DENTAL PLAN. Dental Hygienist - Credentialing Application. City: State: DEGREE: City: State: DEGREE:
*Required Fields LIBERTY DENTAL PLAN Dental Hygienist - Credentialing Application Please complete one application per Dental Hygienist Demographic Information: Male Female *HYGIENIST NAME: RDH Other *DATE
DOD INSTRUCTION DRUG TAKE BACK PROGRAM
DOD INSTRUCTION 6025.25 DRUG TAKE BACK PROGRAM Originating Component: Office of the Under Secretary of Defense for Personnel and Readiness Effective: April 26, 2016 Releasability: Approved by: Cleared
5. returning the medication container to proper secured storage; and
111-8-63-.20 Medications. (1) Self-Administration of Medications. Residents who have the cognitive and functional capacities to engage in the self-administration of medications safely and independently
Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology
Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology Patient Health Questionnaire Patient s Name: Date of Birth: Drug / Food Allergies: Please list any and all allergies you
Beck & Blackley Chiropractic Clinic
Address City State Zip Code Home Phone Cell Phone Work Phone Email Address Sex: M F Marital Status: M S D W Date of Birth SS# Spouse Name How did you hear about our office? Employer Name/Occupation Emergency
*MEDICATIONS BEING ORDERED Please note that all prices and quantities will be confirmed with you before processing your order.
CANADIANPHARMACYKING.COM Unit #202A 8322 130 th Street Surrey, BC, Canada V3W 8J9 Telephone: 1-877-745-9217 Fax: 1-866-204-1568 Instructions for completing this form and getting your medications: 1. Please
Family Cord Blood and Cord Tissue Banking Enrollment Documents Services Agreement
Family Cord Blood and Cord Tissue Banking Enrollment Documents Services Agreement The undersigned expectant parent(s) ( Client ) are electing to enter into the Services Agreement ( Agreement ) for CORD:USE
(b) Service consultation. The facility must employ or obtain the services of a licensed pharmacist who-
420-5-10-.16 Pharmacy Services. (1) The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.75(h) of Title 42 Code of
Chapter 52. Board of Pharmacy.
Chapter 52. Board of Pharmacy. (Words in boldface and underlined indicate language being added; words [CAPITALIZED AND BRACKETED] indicate language being deleted. Complete new sections are not in boldface
Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology
Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology Patient Health Questionnaire Patient s Name: Date of Birth: Drug / Food Allergies: Please list any and all allergies you
Enrollment Application for the Novartis Patient Assistance Foundation, Inc.
Novartis Patient Assistance Foundation, Inc. Enrollment Application for the Novartis Patient Assistance Foundation, Inc. Information P.O. Box 52029, Phoenix, AZ 85072-2029 Phone: 1-800-277-2254 Fax: 1-855-817-2711
Reducing Pharmaceutical Waste March 26, 2009
Reducing Pharmaceutical Waste March 26, 2009 Prescription medications are critical to maintaining health and improving the quality of life for millions of Americans. Not all medications dispensed to patients,
a remote pharmacy is not necessarily intended to provide permanent??? how do we make it so that it may be only for limited duration.
Board of Pharmacy Administrative Rules Version 12 January 18, 2013 Part 19 Remote Pharmacies 19.1 General Purpose: (a) This Part is enacted pursuant to 26 V.S.A. 2032 which initially authorized the Board
(PLEASE PRINT) Sex M F Age Birthdate Single Married Widowed Separated Divorced. Business Address Business Phone Cell Phone
(PLEASE PRINT) Emma Warner, MSW, LCSW, ACSW Tulsa, OK 74105 (918) 749-6935 Personal Information Name Address Last Name First Name Initial Home Phone Soc. Sec. # City State Zip Sex M F Age Birthdate Single
Stewardship Policy No. 15
Page 1 of 13 REVIEW BY: 12/07/19 POLICY It is the policy of Catholic Health Initiatives (CHI), and each of its tax-exempt Direct Affiliates 1 and tax-exempt Subsidiaries 2 that Operates a Hospital Facility
Notice of Privacy Practices
Notice of Privacy Practices Fuquay Eye Care 505 N. Judd Pkwy., N.E., Suite 109, Fuquay Varina, NC 27526 919-557-0308 www.fuquayeye.com Dr. Patrick O Dowd, Privacy Official 2-22-2017 We respect our legal
Person to Contact in Case of Emergency. THE COUNSELING PLACE YOUTH INTAKE FORM Yearly Family Income:
Person to Contact in Case of Emergency Name Relationship Best Contact Number Alt. Number Office Use Only Intake Date Reason for referral Counselor Who Can Pick Up Client (if Minor) THE COUNSELING PLACE
Effective Date: 11/09 Policy Chronicle:
Title: Investigational Drug Service Functions Policy Type: Clinical Operations Replaces (supersedes): Title: N/A Policy Chronicle: Date Original Version of Policy was Effective: 09/06 Reviewer Signature:
NATIONAL ASSOCIATION FOR STATE CONTROLLED SUBSTANCES AUTHORITIES (NASCSA) MODEL PRESCRIPTION MONITORING PROGRAM (PMP) ACT (2016) COMMENT
1 NATIONAL ASSOCIATION FOR STATE CONTROLLED SUBSTANCES AUTHORITIES (NASCSA) MODEL PRESCRIPTION MONITORING PROGRAM (PMP) ACT (2016) SECTION 1. SHORT TITLE. This Act shall be known and may be cited as the
LIBERTY DENTAL PLAN. Provider Credentialing Application. (* Required Fields) *OFFICE PHONE #: ( ) EMERGENCY PHONE #: ( ) *FAX #: ( )
(Complete one application per Provider) (* Required Fields) Credentialing Information: Owner: Associate: *PROVIDER NAME: DDS DMD Other (specify) *DATE OF BIRTH: / / Gender: Male Female Owning Dentist Name:
Informed Consent for Treatment
Informed Consent for Treatment TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended diagnostic, physical therapy or rehabilitation treatment/procedure
NOTICE OF PRIVACY PRACTICES
535 East 70th Street New York, NY 10021 (212) 606-1000 Specialists in Mobility NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need.
Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need. Did you know that NeedyMeds has thousands of other free resources?
NOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES Effective Date: May 31, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
Prescriber/Patient Enrollment Form MS Completion of all pages is required.
Date of birth: Patient name: Street address: / / (MM/DD/YYYY) City State ZIP Work telephone - - Home telephone - - Patient SSN - - Please attach copies of both sides of patient's insurance and pharmacy
SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE
SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE Subject: USES AND DISCLOSURES FOR Page 1 of 3 MARKETING ACTIVITIES No. HIPAA-13 Prepared by: Shoshana Milstein Original
NeedyMeds
NeedyMeds www.needymeds.org Find help with the cost of medicine Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need.
Charity Care Application: An application used by SHC financial counselors and designed to determine if patients are eligible for Charity Care.
POLICY NAME: EFFECTIVE DATE: 1/18/16 PAGE: 1 of 8 PURPOSE: Shriners Hospitals for Children (SHC) is committed to providing care to children with neuromusculoskeletal conditions, burn injuries and certain