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Referring Physician: ___________________ Name: _____________________ _____________________ _______ Sex: Male/Female Date of Birth: _____________ Marital status: _____________ Number in household, including yourself: _________ Emergency contact: ____________________ Phone: _____________________ INCOME INFORMATION: Income from ALL MEMBERS of the household must be included. Please indicate monthly amounts below: Employment: $_____________________ TANF: $________________ Social security/disability $___________ Pension: $_______________ Alimony/child support: $_____________ Other: $________________ MEDICAL INSURANCE INFORMATION: Please Circle Do you have medical insurance through the Veterans Administration? Y / N Do you have medical insurance through Medicare? Y / N Do you have medical insurance that pays for prescriptions through Medicaid? Y / N If you have insurance through Medicaid that does not cover prescriptions, please specify which type you have. (QMB, SLMB, QDWI, etc.) _____________ Have you ever applied for Medicaid? Y / N If yes, please indicate below Date applied: __________________ Reason for denial: ________________________ List all current medications, strengths, and how often taken:
Are you allergic to any medications? Y / N Please read the statement below and sign application: I HEREBY STATE THAT THE INFORMATION ABOVE IS ACCURATE AND I GIVE MY PERMISSION FOR THE ABOVE INFORMATION TO BE RELEASED TO ANY PHARMACEUTICAL COMPANY WITH REGARDS TO REQUESTS FOR DONATED MEDICATIONS. PHARMACEUTICAL ASSISTANCE PROGRAM I hereby authorize, MedsHelp (my “agent”), to complete all applications,
forms, and/or other documents or instruments my agent may consider appropriate
for purposes of ordering or requesting pharmaceuticals pursuant to any program(s)
for free or discounted pharmaceuticals (the “programs”). I understand that this
authorization is intended to enable faster processing, but I understand that
neither my agent nor any other party is obligated to complete any particular
application or to pursue participation in any program. I agree that all
information that I have provided may be used for purposes of completing
applications and other forms in connection with the programs, and I agree that
all information that I have provided so far and any information that I may
provide in the future is accurate and complete. I agree to notify my agent in
writing in the event any of the information that I have provided changes,
including any information concerning financial resources, Medicaid eligibility
or other similar information. I agree to submit proof of my income upon request
by any program and agree that my agent may sign documents on my behalf under
which (1) I will be committed to provide income information to programs, (2) I
authorize the programs to obtain insurance coverage information from insurance
companies and any other information necessary or appropriate for purposes of
applying for participation in the programs. I understand that, in the event that
I receive free or discounted pharmaceuticals pursuant to a program, I will not
submit an insurance claim or other claim for payment to any third-party payer
for the pharmaceuticals. I agree not to resell, offer for sale, trade or barter,
or return for credit any pharmaceuticals, and I agree that any pharmaceuticals
that I receive will be used only for my personal use. I authorize my agents to
execute documents to permit release of information to the programs and to
authorize the programs to use and disclose information.
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