Common Patient Assistance Program Application (Hiv)
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COMMON PATIENT ASSISTANCE PROGRAM APPLICATION (HIV)
Tool
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PROGRAM DESCRIPTION
The purpose of this enrollment tool is to collect information that numerous pharmaceutical companies and foundations providing the donated products of pharmaceutical
companies require for enrollment in various HIV patient assistance programs (PAPs). These PAPs provide medicines at little or no cost to eligible patients. To facilitate
enrollment in multiple PAPs, this tool consolidates all of the necessary information in one place. In each instance in which the tool refers to "PAPs" it means all of the PAPs
for which the applicant may be eligible. Each PAP will determine a patient's eligibility for assistance based on their individual program requirements.
PATIENT GENERAL INFORMATION
Name (First):
(Middle):
(Last):
Mailing Address:
City:
State:
Zip:
Phone:
Ok to call? E-mail
Language:
English
Spanish
Other:
(optional)
Gender:
M
F
Date of birth:
Number in Household (circle): 1 2 3 4 5 6 7 8 9
Current Annual Household Income: $
COVERAGE INFORMATION
(check all that apply)
AIDS Drug Assistance Program:
Enrolled
Denied
Pending
Not Applied
Not Eligible
Waitlisted
Pending
Not Applied
Not Eligible
Medicaid:
Enrolled
Denied
Pending
Not Applied
Not Eligible
Medicare:
Enrolled
Denied
Pending
Not Applied
Not Eligible
Medicare Part D:
Enrolled
Denied
Private Insurance Drug Coverage
VA
Other:
PHYSICIAN/PRESCRIBER INFORMATION
Name (First):
(Middle):
(Last):
Business/Facility Name:
Phone:
Fax:
Office Contact Name (First):
(M.I.):
(Last):
Mailing Address:
City:
State:
Zip:
National Provider Identifier:
Tax ID #:
DEA #:
State License #:
ALTERNATE SHIPPING INFORMATION
(some PAPs require medication to be shipped to physician/prescriber while others will ship to the patient's alternate shipping address of choice)
Name (First):
(Middle):
(Last):
Business/Facility Name:
Phone:
Fax:
Shipping Address:
City:
State:
Zip:
Relationship to patient:
Reason for alternate:
ADVOCATE INFORMATION
(if applying on behalf of patient)
Name (First):
(Middle):
(Last):
Business/Facility Name:
Phone:
Fax:
Street Address:
City:
State:
Zip:
Relationship to patient:
This tool was developed with the assistance of the Department of Health and Human Services/Health Resources and Services Administration.
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