Patient Assistance Program For Medicare Beneficiaries Page 2

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Mail to: Boehringer Ingelheim CARES Foundation, Inc.
PO Box 66745
St. Louis, MO 63166-6745
Telephone 1-800-556-8317
Hours of Operation: Monday – Friday 7:30 am – 5:30 pm CST
Fax: 1-866-727-5891
Patient Assistance Program for Medicare Beneficiaries
Section 1 - Physician and Prescription Information
Physician Name
DEA or State License #:
Phone:
(
)
Fax:
(
)
Address:
City:
State:
Zip:
Prescription
Product Name/Strength
Quantity
Product Name/Strength
Quantity
Physician/Prescriber Attestation: To the best of my knowledge, this patient has no medical insurance other than Medicare Part D for this prescription. Patients on Medicaid
and other public assistance programs are ineligible. I verify that the information provided is complete and accurate to the best of my knowledge. I understand that the
medication prescribed above shall be sent to my office for dispensing to this patient, and I certify that the medication requested above shall only be used to treat this patient
and I shall not seek reimbursement for this medication from any third party, including Medicare Part D.
Physician Signature:
Date:
Section 2 - Patient Information
Patient Name:
SS#:
-
-
Street Address:
Date of Birth:
Male
Female
/
/
City
State
Zip
Phone
(
)
Number of Household members (including self)?
U.S. Resident?
Are you a Veteran of the US
Are you Disabled?
(circle one)
Armed Forces?
1
2
3
4
5
6
7
greater than 7
Yes
No
Yes
No
Yes
No
Section 3 - Financial Information
Note:
You must attach copy of your most recent federal Income Tax Return, i.e.,IRS Form 1040, 1040A, 1040EZ, 1099
List All Sources, Gross Monthly Amounts
Salary/Wages
$_______________
Social Security $_______________
Child Support/Alimony $_______________
Pension/
Unemployment/
Disability
$_______________
Retirement
$_______________
Work Comp
$_______________
Total Gross Household Monthly Income: $_______________
Section 4 – Social Security Low Income Subsidy (LIS)
Note: A LIS Denial letter must be attached.
1. Are you eligible for Low Income Subsidy for Medicare Part D?
Yes
No
Unsure
Application Pending
2. Have you received a denial letter from the Low Income Subsidy?
Yes
No If yes, please attach a copy with your
application.
3. If you received a denial from Low Income Subsidy by phone or do not have a copy of your denial letter, please initial the
following statement:
I confirm that I have received a denial (verbal or written) from the Medicare Part D Low Income Subsidy .
_____
initial here.
Section 5 – Prescription Drug Information
Private Drug Coverage
Medicaid
Medicare
Medicare Part D
Yes
No
Yes
No
Yes
No
Yes
No
$____________
Total Amount Spent on Prescription Medications Since January 1 (required):
Note
: In order to be eligible, a patient must have spent at least 3% of their annual household income on prescriptions during the current
calendar year. You must attach a copy of the most current Explanation of Benefits from the Medicare prescription drug plan or a print-out from
the pharmacy.
Section 6 – Patient Attestation and Signature (required)
I certify that this information is complete and accurate to the best of my knowledge, and that I am unable to afford the medication requested. I understand that additional information
may be requested to process this application, but that all medical and financial information will be kept confidential as required by law. I understand that the Product(s) made available to
me under this program may be denied to me if I do not fully cooperate with efforts made to verify the information provided in this application, or if I do not take steps to secure alternative
means of prescription coverage that are available to me, after I become aware of such alternatives. I certify that I shall not seek reimbursement for any medication dispensed as part of
this program. I hereby authorize the Boehringer Ingelheim CARES Foundation, Inc. to obtain and disclose information from physicians, insurance companies and other information as
necessary to verify the information provided in this application although Boehringer Ingelheim Cares Foundation, Inc. is not obligated to verify any of the information contained in Section
1 above or confirm other medications that I am taking.
Patient’s Signature:
Date:
BI SF APP 12/05/07

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