Bobby Goldsmith Foundation Client Medication List

ADVERTISEMENT

Bobby Goldsmith Foundation Client Medication List
Please note-Submitting this form does not guarantee eligibility for co-payment or financial
assistance.
To seek financial assistance for your medications, vitamins, supplementary and complimentary
therapies your prescribing doctor must complete this page.
Only medication and therapies prescribed by your doctor will be considered for financial assistance.
Annual caps apply. Regular reviews of assistance agreements will be conducted.
Client Name _____________________________________
DOB__________ ______________
HIV Medication
Antiretroviral medication
PBS
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Comorbid Medications
Condition
Medication
PBS
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Vitamins & Supplements
Name
Dose
Complementary Therapies
Name
Frequency
Prescribing Doctor _______________________________
Signature ______________________________________
Date _________________________________________
Surgery / Clinic stamp
Medications will only be approved for subsidy following proof of eligibility via the assessment intake process. BGF provides approved clients
with access to antiretroviral medication on account at several major hospital pharmacies. BGF also provides approved clients with financial
assistance to obtain HIV related Non PBS listed medication and comorbid medication. Total invoice amount needs to be $15 or more.
I, _________________________________ give consent for my medication details to be given to BGF.
Client Signature ____________________________________
Date __________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go