Referral Packet by DI0rR5B


            .                                                               PO Box 42678
            .                                                               Baltimore, MD 21284
            .                                                               Toll Free 1-877-435-7755
            .                                                               Local 410-821-9262
            .                                                               Toll Free Fax 1-877-307-6166

           MEDBANK of Maryland, Inc.
MEDBANK is a non-profit organization that provides free prescription medications for low income
chronically ill patients who are uninsured or under insured and live in Maryland or see a physician in
Maryland. MEDBANK collects information from the patient and their physician that is required by the
drug companies.

Over the course of a year you will be receiving hundreds and in many cases thousands of dollars worth of
free medications. There is an administrative fee of $10.00 per month which helps to support the operating
costs of the organization. You will not be obligated to pay any fee until you have received your first

       You must live in Maryland or see a physician whose office is in Maryland
       You do NOT have a prescription benefit as part of your health insurance coverage
       You meet the financial guidelines set by the drug companies

       Complete and sign the two page patient questionnaire
       Make copies of proof of income for all sources of income
       If you have Medicare or other health insurance, make a copy of your Medicare/Insurance
       Take your patient questionnaire, proof of income, copy of Medicare or insurance card and
        physicians referral form to your doctor’s office.
       Ask them to complete the physician referral form and fax or mail it to our office with all of your

The Patient Service Representatives at MEDBANK process your applications. MEDBANK has a
pharmacy that stocks over 100 medications. If the medication you need is stocked in our pharmacy, we
will send it to your doctor’s office for you to pick up. If we do not stock the medication in our pharmacy,
we will apply to the drug companies’ Patient Assistance Programs for the medicine your doctor has
prescribed for you. In most cases you will receive a 90 day supply of each medicine you are taking.

When you pick up a medication from your doctor’s office, please call the MEDBANK office and let us
know the name of the medicine you have picked up. We will track when it is time to renew your
medication. When your first prescription is almost gone, another 90 day supply will be waiting for you at
your doctor’s office. If at any time you stop taking a medication or your doctor prescribes a new
medication, it is very important to call the MEDBANK office and let them know. If you do not call us
when you pick up your medication, you will not receive your next 90 day supply.

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Call MEDBANK to see if you are eligible for the program. The toll-free number is 1 (877) 435-7755, the local number is
(410) 821-9262. You will be asked several questions about your income and any prescription coverage you may have. If you
meet the eligibility requirements for MEDBANK, you will be mailed a new patient packet.

           When you receive your new patient packet you will need to do the following:
   1. Complete the two-page patient questionnaire and sign the bottom of the form
   2. Sign the 4506-T form if you did not file an income tax return. This form is verification that you do not file
      an income tax return.
   3. Make copies of your income. If you are married, please also include copies of your spouse’s income.
   4. If you have Medicare or other health insurance , we need a copy of your Medicare or other insurance card.

                                    What you may send as proof of income:
          If you file an income tax return, please send a copy of your most recent Federal tax return
           If you have not completed your 2008 income tax return, please send us your 2007 return. We will need your
           2008 return on or before April 15, 2009.
          A copy of your Social Security Benefit letter for 2009
          Current Pension statements
          Child support or alimony court order
          If you are working, copies of the last eight weeks of pay stubs or unemployment stubs
             Please do not send W-2 forms. The drug companies do not accept W-2’s as proof of income

Take your completed patient questionnaire, copies of proof of income, copy of Medicare/insurance card, signed 4506-T form
and the Physician referral form to your doctor’s office and ask them to complete the physician form. Your doctor’s office
must complete the Physician Referral Form.

               Either the doctor’s office or the patient can mail or fax all of the information together.

                                           MEDBANK of Maryland, Inc.
                                                P. O. Box 42678
                                              Baltimore, MD 21284

                                            Fax # Local (410) 821-9265
                                             Toll-Free 1 (877) 307-6166

                Please call the MEDBANK office if you have any questions. The toll-free number is
                               1 (877) 435-7755. The local number is (410) 821-9262.

                 Please complete every blank on the patient questionnaire.
                      Incomplete questionnaires cannot be processed.

                                  The bridge to brighter days ahead.
                       MEDBANK Patient Questionnaire/ Application
PRINT OR               Toll free Number: 1-877-435-7755 Fax: 1-877-307-6166
TYPE ONLY                           Local Number: 410-821-9262

                (PLEASE CHECK ONE)             NEW Patient             Patient Update
Who referred you? __________________________________
Section 1. Please follow the instructions on page 2 as you fill each box below:
Last Name                  First Name and M.I.         Social Security Number          Date of Birth

Mailing Address with       City                             State                      Zip Code
Apt. #
Home Phone ( )             Work or Cell Phone (        )    Marital Status             County

Sex                        Race                             Primary Language           Are you a US
                                                            Spoken                     Citizen? Yes / No
Section 2. Do you have any of the benefits listed below? Circle Yes or No for each one. Do not leave
anything blank. Medical Supplemental Insurance and Life Insurance policies do not need to be reported.
      Medicaid                          Yes   No       Applying for Medicaid or PAC?Yes      No
      Medicare                          Yes   No       Date applied for Medicaid or Pac
      Medicare Part-D                   Yes   No
      Private Health Insurance          Yes   No       If Yes, What is the name?
      VA Health Benefits                Yes   No
Do you have prescription coverage: ____Yes ____No
Section 3. How many people live in your house including you: ____Adults ____Children (under age 18)
Section 4. List each person in your house and tell us how much income each one has (list yourself first).
Person’s Name                    Relationship to you       Amount of Monthly         What is the source of
                                                           income received or earned the income?

Section 4a. List the amount of assets that you have next to each source:
$________Stocks     $________Bonds $________Checking Account                   $________Savings Account
$________IRA’s      $________Annuities $________Other
Section 5. Please attach copies of your proof of income for each person listed above who has income. Please
see the Application Instructions to see what will be acceptable. If you are not sure what to send, please call
our toll-free number 1-877-435-7755 and we will help you. Please do not send original documents.
Section 6. Do you attend a clinic? _____ If Yes, which clinic? _____________________________________
Section 7. Do you have a doctor? _____ If Yes, what is your doctor’s name? ________________________

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                          MEDICAL HISTORY 
Section 8. Do you have any medical allergies? _____ If Yes, which ones? ___________________________

Section 9. Put a check mark  if you have:                      ___Acid Reflux/ Ulcers                 ___Allergies       ___Arthritis

___COPD (Emphysema, Chronic Bronchitis)                         ___Asthma                       ___Depression             ___Diabetes

___High Cholesterol                  ___Hypertension (high blood pressure)                      ___Seizures               ___Thyroid

___Other illness, physical disability, or medical problem (please explain):_____________________________
              If at any time during the year your income changes or you obtain prescription coverage,
                                       please notify MEDBANK immediately.
Section 10. PLEASE READ THIS STATEMENT AND SIGN & DATE THAT YOU AGREE:                                                      .

I authorize MEDBANK of Maryland, Inc. to:

1.   Obtain pertinent information, when needed to solicit medications on my behalf from companies that manufacture or provide them
     through the patient assistance programs.
2.   Discuss me and my medical needs with my physician/prescriber, whenever necessary.
3.   Verify my income or health insurance coverage through any government agency, employer, company, business, and/or
     organization from which I receive income or health insurance.
4.   Provide information to and sign forms on my behalf for the purpose of soliciting medications on my behalf from companies that
     manufacture or provide these medications through patient assistance programs.
5.   Ship these medications, when necessary, to my current physician/prescriber’s designated facility for pick-up.

This authorization is binding for a period of one year from the date this document is signed, and for as long as MEDBANK is assisting
me, or until I revoke my consent. I also agree that a copy of this form can be accepted as a valid consent to share information.
Moreover, I understand that if I do not sign this form, information will not be shared, and I will have to contact each agency, company, or
organization individually to give them the information about me that they need.

I certify and attest that the information given in this application is accurate and true to the best of my knowledge. I will notify
MEDBANK of Maryland, Inc. if I become eligible for Medicaid, Medicare, health insurance or VA benefits.

 Signature:                                                                          Date:

 Printed Name Of Patient:

 DOB:                                                                Social Security Number:


I authorize MEDBANK of Maryland, Inc. to communicate with the following friend, family member, or other personal representative on my
behalf, as necessary:

 Name:                              Telephone:                                                 Relationship to patient:

 Signature:                                                                          Date:

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The bridge to brighter days ahead.
MEDBANK of Maryland, Inc. is a non-profit whose mission is to provide access to free prescription medications
for low income chronically ill patients throughout Maryland. MEDBANK has been in operation since February,
2000, and has provided over $113 million dollars (AWP) worth of free medications to residents in the state of
Maryland, We are funded partially by the Department of Health and Mental Hygiene. We also receive funding
from pharmaceutical companies, CareFirst, United Way and other private foundations.

It is the responsibility of MEDBANK to pre-qualify patients for the program based on the requirements
set by the drug companies. We gather all of the necessary information from the patient and the
physician to determine eligibility. If a patient is eligible, a 90 day supply of medications is shipped
directly to the patient’s physician. The patient picks up their medications at their doctor’s office.

Your patient has contacted us for assistance with their medications. We ask that you complete the
physician referral form for your patient. Please prescribe only brand name medications. A formulary
listing the drugs available is attached for your convenience. MEDBANK operates its own pharmacy
where pharmaceutical companies give bulk shipments of medications for MEDBANK to dispense.
Please note on the formulary all of the medications that are followed by a “p” are the ones we stock in
our pharmacy. Whenever possible we ask that you select from our pharmacy medications. The patient
can receive them much more quickly and the paperwork involved is minimal. For the medications we
do not stock in our pharmacy we apply directly to the pharmaceutical companies’ Patient Assistance
Programs. The pharmaceutical companies make the final determination on patient approval to their

Either the doctor’s office or the patient can fax or mail the completed patient and physician referral
forms along with the patient’s proof of income to MEDBANK.

                                  MEDBANK of Maryland, Inc.
                                  P. O. Box 42678
                                  Baltimore, Maryland 21284

                             Local fax number: 410 821-9265
                            Toll-free number: 1 877 307-6166

 MEDBANK also has a free discount prescription card that can be used to cover medications for patients who are over
income for the MEDBANK program. There are no income requirements or restrictions on the discount card and the patient
can save between 15 and 40% on their medications. To request a supply of free discount prescription cards or if you have
any questions about the referral process, please call our office at (410) 821-9262 locally or 1 (877) 435-7755 toll free.

                               The bridge to brighter days ahead.
MEDBANK of Maryland, Inc.

 The bridge to brighter days ahead.

 PRINT OR                    Physician/Prescriber Referral for Medications
 TYPE ONLY                          NEW MEDBANK Patient Only
                             Local Number: 410-821-9262
                              Toll free: 1 877-435-7755           Fax: 410-821-9265

Referral Date:                     Who can answer questions about this referral?
Name of Clinic/Hospital associated with this referral:

Patient Last Name                           First Name                             Social Security Number

Last Name:                                           First Name:                                   MI:
Specialty:                        Title:                       DEA#:                     Exp:
State License #:                           State:              Exp:                   UPIN #:
Suite/Building:                                        E-mail Address:
City:                                 State:                                Zip:
Office Contact:                                Phone #:                               Fax #:
      MEDICATION                   DOSAGE                FREQUENCY                     DIAGNOSIS
    (Do not list generics)

Please indicate below if you wish correspondence or medications directed to an alternate physician address:

Prescriber’s Signature:                                                    Date:

Personal information submitted will be treated with confidentiality and viewed only by MEDBANK personnel.

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  Medications available through MEDBANK of Maryland’s Pharmacy*
 *Whenever possible please prescribe from the Medbank formulary to expedite processing time
and reduce paperwork. We will go directly to the pharmaceutical companies for expensive brand
name medications for conditions such as diabetes, mental illness, HIV, cancer, MS, transplant and
                    heart related conditions that are not on our formulary.

Allergies                Asthma                     Hyperlipidemia            Incontinence
Rhinocort                Accoloate                  Advicor                   Detrol
Vistaril                 Azmacort                   Crestor                   Detrol LA
                         Pulmicort Respules         Lescol                    Enablex
Alzheimer’s              Pulmicort Flexhaler        Lescol XL
Disease                  Singulair                  Lipitor                   Migraines
Aricept                  Symbicort Inhaler          Lopid                     Maxalt
Exelon                                              Niaspan                   Maxalt MLT
                         Corticaldepressant         Tricor                    Relpax
Antibiotic               Vistaril
Vibramycin                                          Hypertension/Cardiac      NSAID
Zithromax                Cytoprotective             Accupril                  Celebrex
Zitromax Z-pak           Cytotec                    Accuretic                 Feldene
Anticonvulsants          Dermatologic               Atacand HCT               Oncology
Depakote                 Elidel Cream               Caduet                    Arimidex
Depakote ER                                         Cardizem LA               Casodex
Dilantin                 Diabetes                   Cardura                   Emend
Neurontin                Diabinese                  Covera HS                 Nolvadex
Trileptal                Glucotrol                  Cozaar                    Zoladex Inj
Tegretol-XR              Glucotrol XL               Diovan
                         Janumet                    Diovan HCT                Osteoporosis
Anti-fungal              Januvia                    Exforge                   Fosamax
Diflucan                 Starlix                    Hyzaar                    Fosamax Plus D
Antidepressant           Dizziness                  Minipress                 Parkinson’s
Zoloft                   Antivert                   Nitrostat                 Disease
                                                    Norvasc                   Comtan
Anti-psychotic                                      Plendil                   Exelon
Geodon                   Erectile                   Procardia                 Stalevo
Navane                   Dysfunction                Procardia XL
Seroquel                 Viagra                     Tarka                     Thyroid
Seroquel XR                                         Tekturna                  Replacement
                         GERD                       Teveten                   Synthroid
Anti-HIV                 Nexium                     Teveten HCT
Crixivan                                            Toprol XL
Isentress                Glaucoma
                         Cosopt                     Hyperprolactemia
Anti-viral               Trusopt                    Dostinex
Famvir                   Xalatan

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