Azilect Patient Assistance Program - Needymeds Page 3
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1
2
3APPLICATION FORM
AZILECT® (rasagiline tablets)
AZILECT®
P. O. Box 139
Phone: (866) 217-7163
Patient Assistance Program (PAP)
Fax: (866) 838-5832
Somerville, NJ 08876
Page 2 of 2
Prescribing Practitioner Information
Patients Name ____________________________________________
D.O.B. ______________________________
Practitioner Name ____________________________________________
Phone # (____) _______________________
Office Address _______________________________________________
Fax# (____) __________________________
(Street Address Only)
Contact Person _________________________
City____________________________State___________Zip__________
NPI # _________________ DEA or State License #:__________________
SHIP ORDER TO:
q Prescriber or q Patient
Prescription Information
Other Health Conditions:
AZILECT®
Quantity:
Refills:
1 per day - max 90 days
1 year q
Strength: q 0.5 mg
Allergies: __________________
Is this a dosage increase from
q 1.0 mg
previous order?
Other meds: ________________
q Yes q No
To the best of my knowledge the information contained in this application is complete and accurate and this patient has no or
insufficient prescription insurance coverage either private or public (e.g. Medicaid), and meets the required income limits for
participation in this Program. If I become aware of a change in income or insurance status that may affect Program participation
of this patient, I will alert Program Sponsor. I understand that AZILECT® Patient Assistance Program reserves the right to modify or
terminate this program at any time without notice. I attest that I am not on the HHS/OIG list of Excluded Individuals. My signature
certifies that prescription products received from AZILECT® Patient Assistance Program will be used for the above named patient
only and will not be resold nor offered for sale, trade or barter and will not be returned for credit. I agree to participate in any recall
of the product initiated by the manufacturer.
LICENSED PRACTITIONER SIGNATURE (NO SIGNATURE STAMPS, PLEASE)
DATE
AZI-N-3268
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