Pap form
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This document is an application for the ATRIPLA Patient Assistance Program. It requests personal information about the patient such as name, address, income sources, insurance status, and medical information including diagnosis codes. If approved, the program will provide ATRIPLA medication at no cost. The applicant and prescriber must sign to authorize the disclosure and use of the patient's information for determining eligibility and program support.
Pap form
- 1. PLEASE PRINT Name (First): Address: U.S. Resident: YES NO Patient Language: English Spanish Other: Gender: M F Salary/Wages: $ Social Security Retirement: $ Supplemental Security Income: $ Social Security Disability: $ Unemployment: $ Alimony/Child Support: $ Rental Income: $ Workers Compensation: $ Veterans Benefits: $ Pension/Retirement: $ Other: $ TOTAL: $ Total Annual Household Income (Attach Proof of Income for each Source Listed) Insurance Information (Y = Yes, N = No) Insurer/Payer/Program Insurer/Payer/Program Insurer/Payer/ProgramRx Benefits (circle) Y N Y N Y N Y N Y N Y N Y N Y NY N Y N Medicaid AIDS Drug Assistance Program Is applicant eligible? Y N If Y, Date of Application: If N, state reason: Medicare Part D Private Insurance Other No Insurance Medical Benefits Rx Benefits (circle) Medical Benefits Rx Benefits (circle) Medical Benefits Check if Applicable (Last) State:City: Social Security #: Birth Date: MM DD YYYY / / ZIP Code: Phone #: ( ) (Middle Initial) Contact Name: Policy ID#: Group#: Household Size (Number of persons who contribute to or are dependent on patients household income): Primary Insurance Company: Secondary Insurance: Does applicant have additional coverage? YES NO If YES, provide name, telephone and policy numbers: List Insurer if Y ICD-9 Code for Primary Diagnosis: ICD-9 Code for Secondary Diagnosis (if applicable): . . . . To receive ATRIPLA (efavirenz 600 mg/ emtricitabine 200 mg/ tenofovir disoproxil fumarate 300 mg) Tablets, please call: 1-866-290-4767 Page 1 of 2 Complete Page Two on Reverse >> Phone #: ( ) Subscriber Name: Date of Birth: Has applicant applied for Medicaid or Medicare Part D? YES NO If YES, date of application: Is applicant eligible? YES NO Currently enrolled in Medicare Part D? YES NO If NO, state reason: 1 Patient Information Voucher ID Number: Bin Number: 610020 Group Number: 99990838 ATRIPLA速 (efavirenz 600 mg/emtricitabine 200 mg/ tenofovir disoproxil fumarate 300 mg) Tablets To the Provider or Patient Advocate: Please enter the Voucher ID Number. 697US07PM088/SU0446 Rev.12/07 Void where prohibited by law. Patients who are enrolled in Medicaid or have coverage for prescription drugs under any other public program or have such coverage from any other third party payer, are ineligible for the ATRIPLA Patient Assistance Program. ATRIPLA速 Patient Assistance Program Reimbursement Assistance for Patients in Need ATRIPLA速 Patient Assistance Program PRESCRIPTION VOUCHER
- 2. Statement of Medical Necessity4 Name: State: Facility Name: Street Address: ZIP Code: DEA #: NP/PA #:State License #: Name: Applicant Declaration Fax #: ( )Phone #: ( ) Patient Advocate Information (If Different from Prescriber) City: Title: Title: State: ZIP Code: Fax #: ( )Phone #: ( ) Facility Name: Street Address: City: State License Type and Number (if applicable): A Patient Advocate may be a healthcare worker involved in the patients care a physician, nurse, physician assistant, social worker or case manager. Friends or family members cannot act as Patient Advocates. Patient Advocates are responsible for completing the patient Enrollment Form and working with the patient at specific intervals in the enrollment process. Prescriber Information I verify that the information provided in this application is complete and accurate. I understand that the ATRIPLA Patient Assistance Program may request documentation to verify financial or insurance information, and that any assistance in the form of free medication is contingent upon meeting the program eligibility criteria. I also understand that Bristol-Myers Squibb & Gilead Sciences, LLC reserves the right at any time, and without notice, to modify the application form; modify or discontinue this program and its eligibility criteria; or terminate assistance. I authorize the ATRIPLA Patient Assistance Program to obtain information from my prescribing physician, insurance company, and other sources as deemed necessary to ensure the accuracy and completeness of this application. I authorize my healthcare providers and health plans to disclose personal and medical information about me, including information about my HIV status, to Bristol-Myers Squibb & Gilead Sciences, LLC and its agents and contractors (BMS-Gilead) and I authorize Bristol-Myers Squibb & Gilead Sciences, LLC to use, share and disclose this information to: 1) establish my benefit eligibility; 2) provide support services, including facilitating the provision of ATRIPLA速 to me; and to contact me to evaluate therapy and the effectiveness of the program. I understand that once my health information has been disclosed to Gilead, privacy laws may no longer restrict its use or disclosure, however Gilead agrees to protect my information by using and disclosing it only for the purposes described above or as required by law. I further understand I may refuse to sign this authorization and that if I refuse, my eligibility for health plan benefits and treatment by my doctor will not change, but I will not have access to the services available through this program. I may cancel this authorization at any time by notifying Gilead in writing and submitting it by fax to 1-866-290-4487 or by calling 1-866-290-4767. If I cancel, Gilead will stop using or disclosing my information for the purposes listed above, except as required by law or as necessary for the orderly termination of my participation in the program. I am entitled to a copy of this signed authorization, which expires 10 years from the date it is signed by me. Patient Signature: Date: Statement of Medical Necessity for Financially Needy Patients. To the best of my knowledge, this patient has no coverage (including Medicaid or other public programs) for ATRIPLA (efavirenz 600 mg/emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg) Tablets. I certify that the medication(s) listed above are medically indicated for this patient and that I will be supervising the patients treatment. As part of my patients eligibility, I agree to periodically verify continued use of ATRIPLA and resubmit current prescriptions. Signature: Date: Prescriber Patient Advocate Applications are considered complete only if they include all of the following: Front and Back Pages of Enrollment Form Patient as well as Prescriber or Patient Advocate Signatures Documentation of Income Sources and Residency Copy of Prescription When complete, FAX application and documentation to: 1-866-290-4487 3 2 To the Patient: Please present this Voucher and your prescription to the Pharmacist to receive ATRIPLA free of charge. ATRIPLA (efavirenz 600 mg/emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg) Tablets Help Line: 1-866-290-4767 To the Pharmacist: When this Voucher is affixed to a prescription for ATRIPLA, it is redeemable for a 30-day supply of the medication. This Voucher may only be used one time. Submit all 11 characters of the Voucher ID Number in your pharmacy claims system. Pharmacy Help Line: 1-866-486-6906 Limit one Voucher per patient. No substitutions are permitted. Void where prohibited by law. Not valid if reproduced. Prescriber ID required on prescription. Bristol-Myers Squibb & Gilead Sciences, LLC reserves the right to rescind, revoke, or amend this program without notice. THIS IS NOT AN INSURANCE PROGRAM. ATRIPLA速 Patient Assistance Program P.O. Box 13185 La Jolla, CA 92039-3185 TEL: 1-866-290-4767 FAX: 1-866-290-4487 Page 2 of 2 ATRIPLA速 Patient Assistance Program PRESCRIPTION VOUCHER ATRIPLA速 Patient Assistance Program Reimbursement Assistance for Patients in Need 697US07PM088/SU0446 Rev.12/07 697US07PM088/SU0446 Rev.12/07