Form Lgo-Lc - Patient Assistance Program Information Form

Lilly Cares

PO Box 230999

Patient Assistance Program

Centreville VA 20120

1-800-545-6962

Lilly Cares is a patient assistance program operated and administered by Lilly Cares Foundation, Inc., a tax-exempt operating foundation

created, funded, and supplied by Eli Lilly and Company. Lilly Cares provides free Lilly medications to eligible patients through the patients’

physicians or other authorized prescribers. A patient may not participate in the Lilly Cares program if the patient has private, public, or

government prescription assistance, including Medicare.

• To apply, the prescriber and patient must complete and sign this application.

• If the patient is enrolled, most medications are delivered to the prescriber and the prescriber dispenses to the patient.

• Medications usually arrive at the prescriber’s office 4 weeks after Lilly Cares receives a completed application.

• Patients enroll for a 12-month period and must re-apply annually.

• The prescriber’s office requests refills by faxing the Fax Refill Request Form to Lilly Cares (enclosed with each shipment).

Step One: Prescriber

- Complete section below (please print clearly)

Prescriber’s Name:____________________________________________________________________________________________

(circle:

M.D.

D.O.

N.P.

P.A. )

Mailing Address: Street:____________________________________City:______________________State:_________Zip:__________

Shipping Address: Street:____________________________________City:______________________State:_________Zip:__________

(IF DIFFERENT FROM MAILING ADDRESS) (DO NOT USE PO BOX)

Phone:(________)___________________________

Fax: ________________________________________________

(Prescriber to complete)

Medication Information:

Patient Name:______________________________________________________________________________

Product Requested:________________________________________________Dosage:_____________________________

Sig:__________________________________________________________________________________________

Quantity:__________________________________________________________________________________________

A 4-month supply of most products will be provided unless a lesser amount is requested.

Healthcare Provider’s Attestations and Agreement to Participate in Program:

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 “Healthcare provider”) for

the sole purpose of caring for the ill, needy, indigent, and/or infants in the United States (the “Qualifying Patients”). The Healthcare

provider agrees to accept the Medications from Lilly Cares and deliver the Medications only to Qualifying Patients at no charge of

any kind and further agrees not to use any of the Medications for any other purpose. The Healthcare provider agrees to provide

Lilly Cares ninety (90) days advance notice of any proposed assignment, in full or part, of this agreement. .

My signature immediately below attests to my understanding and agreement to the above Program requirements. I further attest

that I am licensed in the state in which I am prescribing, receiving, storing, and dispensing this Medication to the above patient. I

further attest that if Medications are received from Lilly Cares as a result of this application, I will accept such Medications and

Medications will only be provided to the patient named on this form at no charge. I further attest that this Medication will not be

offered for sale, trade, or barter,. I understand that Lilly Cares has the right to contact the patient directly to confirm receipt of the

Medications, and to revise or terminate the Program at any time. I further attest that all Medications previously received from Lilly

Cares and distributed by me were distributed only to Qualifying Patients

Prescriber Signature:________________________________________________________________________________

Original Signature Only; No Photocopies or Stamps

Date:___________ /__________ /_____________

State of license:____________________________________________________________________________________

State License #____________________________________________________________________________________

License expiration date: _____________________________________________________________________________

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LGO-LC-042009

Form Lgo-Lc - Patient Assistance Program Information Form - Lilly Cares

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