Azilect Patient Assistance Program - Needymeds Page 2
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APPLICATION FORM
AZILECT® (rasagiline tablets)
AZILECT®
Phone: (866) 217-7163
P. O. Box 139
Patient Assistance Program (PAP)
Somerville, NJ 08876
Fax: (866) 838-5832
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Patient Information
Social Security Number __________________
Name _____________________________________________________
Patient Gender: q Male q Female
Street Address _______________________________________________
(No P.O. Box)
Date of Birth __________________________
City____________________________State___________Zip__________
Phone # _____________________________
Patient Representative For Purposes of Program
(if applicable)
I permit the AZILECT® Patient Assistance Program to speak and write to the following person(s) about this form, and I permit the
person(s) to sign any documents related to the Program on my behalf:
Name: _______________________________________ Relationship: _______________Phone: ____________________
1. Is the patient a U.S. resident?
q Yes q No
2. Does the patient have DRUG COVERAGE?
Private plan (such as HMO or PPO)
q Yes q No
Medicare Prescription Drug
q Yes q No
If YES, when did patient enter coverage gap? (month)___________
Other Government coverage
q Yes q No
i.e.: Medicaid, Veteran’s Administration, state or local programs
Drug plan name: _____________________________________Member ID and Group #: ___________________________
3. What is the YEARLY HOUSEHOLD INCOME including wages, social security, disability, etc.? $______________________YEARLY
4. How many people, including the patient, live in the household? (please circle)
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I attest that the above information is complete and accurate. I attest that I have no or insufficient prescription insurance coverage
for the indicated medication, including Medicaid, Medicare or any other public or private program and I have insufficient financial
resources to pay for the prescribed therapy. I understand and agree that PAP medication received will not count toward my true-out-
of-pocket costs (TROOP) as defined under the Medicare Modernization Act. I understand that the PAP medication will be dispensed
to me by my physician or will ship directly to my home and is provided at no charge to me or any other party; therefore, I agree
that I will not submit any claim for the PAP medication to any third party, including my Medicare Part D Plan. By my signature, I
authorize the release of the information about me and my medical condition to Teva Neuroscience and/or their agents. I authorize
AZILECT® Patient Assistance Program and/or their agents to use and disclose such information for the assessment of my eligibility
for and enrollment and administration of the program, which may include contacting my insurer, public funding programs, social
workers, advocacy organizations, healthcare providers, or other persons or entities Teva Neuroscience may deem appropriate to
release all medical records or requested information bearing on my eligibility to and benefits under the program. Additionally,
I agree that at any time during my enrollment, AZILECT® Patient Assistance Program may request additional documentation to
authenticate the statements made on my application. AZILECT® Patient Assistance Program and/or their agents agree to not
disclose any information to any third party except those required for program administration as authorized by me or as required by
law. I understand and acknowledge that this assistance is temporary and that this program may be changed or discontinued at any
time without notice. The information above will append the incomplete information provided on my original enrollment application.
PATIENT OR LEGAL GUARDIAN SIGNATURE
DATE
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