Fillable Common Patient Assistance Program Application (Hiv) (Page 3 of 3) in pdf

COMMON PATIENT ASSISTANCE PROGRAM APPLICATION (HIV)

Tool

3/3

PATIENT AUTHORIZATION

By my signature, I authorize each Program and their agents to do the following:

Use any information that I provide in my application for the purpose of enrolling in or to administer the PAPs;

Contact my doctor, healthcare provider, or pharmacist about my application for the PAPs, and disclose to them information contained in my application, in order to help me receive

Programs’ products under the PAPs and ensure that PAPs’ guidelines are being met;

Request information from my insurer, doctor, healthcare provider, or pharmacist about the prescribed medications I receive or will receive under the PAPs and about my medical

condition. This information will be used only to determine my eligibility for the PAPs and to administer the PAPs. By signing below, I also authorize my insurer, doctor, healthcare

provider, or pharmacist to release information about my prescribed medications and medical condition that is requested by Programs or their agents;

Contact my insurer, other potential funding sources, including the Centers for Medicare and Medicaid Services, social workers or patient advocacy organizations on my behalf in

order to determine if I am eligible for health insurance coverage or other funds, and disclose to them information contained in my PAP applications or information about my

prescribed medications and medical condition that has been provided by my physician, healthcare provider or pharmacist; and

Disclose any information obtained from the sources listed above to third parties if required by law.

By my signature, I am signifying that I understand the following:

Once medical information about me has been disclosed in reliance upon this Authorization, the information may no longer be protected by federal privacy laws and may be further

disclosed; however, Programs agree to protect my information by using and disclosing it only for the purposes described above or as required by law.

Programs and their agents will only ask for the information that is needed to process my application, renew my application or provide me with help throughout my Program

participation. Each Program will only have access to the information needed for that Program and will not have access to information required for enrollment in any other PAP.

This Authorization will remain in effect for as long as I participate in the Program and a period of 5 years after my participation in the Program ends, and that I am entitled to

request a copy of this signed Authorization.

I have the right to revoke this authorization at any time by mailing a signed written statement of my revocation to the address(es) used on page 1. Such a revocation would end

my eligibility to participate in the PAPs. Revoking this authorization will prohibit disclosures after the date written revocation is received, except to the extent that action has been

taken in reliance on my authorization.

5. Any assistance in the form of product at no cost is contingent upon my ability to meet the eligibility criteria for the Program.

6. The program assistance may change or be discontinued at any time without any notice to me.

7. I agree that the Program does not have any liability in providing PAP services to me.

Finally, I understand I may refuse to sign this authorization and that if I refuse, my eligibility for health plan bene ts and treatment by my doctor will not change, but I will not have access to

the services available through this program.

If I receive any free product from Programs, I certify that I will not seek reimbursement from any public or private prescription drug plan for the use of such product.

I certify that the information in this application is complete and accurate to the best of my knowledge and agree to notify PAPs of any change in my insurance eligibility or nancial status

within 30 days by providing that information to the address(es) used on page 1.

Signature (Patient or Legal Representative)

Date

PHYSICIAN/PRESCRIBER CERTIFICATION

By my signature, I certify:

To the best of my knowledge, the information on this patient is correct and complete and consistent with applicable privacy laws and regulations, and I understand that Program

and/or their agents are relying on this representation.

I have no knowledge of any intent to sell, barter or give this product to any person other than the patient for whom it has been prescribed.

No reimbursement of the cost of product will be accepted by me from public or private sources, including patients, for any treatments where product will be provided free-of-charge

by Program.

The medication(s) covered by the PAPs are medically indicated for this patient and that I will be supervising the patient’s treatment.

I agree to periodically verify continued use of Programs’ medication and resubmit current prescriptions.

My State license is currently in good standing, I am not prohibited from participating in Federally-funded health care programs, nor am I on the List of Excluded Individuals/Entities

maintained by the HHS Of ce of Inspector General.

I authorize the Program to forward this prescription to a dispensing pharmacy on behalf of myself and my patient, or to send the medication directly to the patient, or to send the medication

to my of ce for dispensing to my patient in accordance with individual program requirements.

Signature

Date