Compassionate Contraceptive Assistance Program Eligibility

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					               2008
   Revised May
            Compassionate Contraceptive
            Assistance Program:
            Eligibility Application Form
                                                                                              780 promenade Echo Drive, Ottawa, Ontario K1S 5R7
                                                                                                 Tel/Tél. : 1 800 561-2416 or/ou (613) 730-4192
                                                                                                   Fax/Téléc. : (613) 730-4314 www.sogc.org



         FAX THIS FORM TO TOLL FREE NUMBER 1-866-888-PILL (7455)
           OR COMPLETE THE REQUEST FORM AT www.sogc.org/compassionate
Name of Prescribing Physician: PLEASE PRINT, TYPE OR STAMP (PLACE STAMP HERE)
Name: _____________________________________________________________________________________________________
Office Address: ______________________________________________________________________________________________
City: ________________________________________________________ Province: ________ Postal Code: _________________
Tel: (____) ___________________________________________________ Fax: (____) ___________________________________


Dosing Information
 Name of Contraceptive                                  Blister Pack                                Duration Request
      Alesse                          -------------                    28-day                          6 months
      Marvelon                         21-day                         28-day                          6 months
      Tri-Cyclen Lo                    21-day                         28-day                          6 months
      Yasmin                           21-day                         28-day                          6 months
      EVRA Transdermal Contraceptive Patch                                                              3 months
      NuvaRing Vaginal Contraceptive Ring                                                               3 months

Suggestions or comments: ____________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

This program is for compassionate use only. To the best of my knowledge this patient, for whom this request is submitted, is:
 Not covered by a drug reimbursement plan and;
 Cannot afford the medication and/or insurance co-payment fee.

Compassionate Program ID Number: ___________________________________________________________________________

Physician’s Signature: __________________________________________ Date: ________________________________________


All information requested above must be completed in order to process this request.
* Note: - Contact the SOGC if you have not received a confirmation of your order within two business days.
        - Allow 4-6 weeks for product delivery.
        - The Compassionate Contraceptive Assistance Program provides free prescriptions for a duration of 6 months
          (3 months for EVRA & NuvaRing) to patients whose financial hardship becomes a barrier in obtaining contraceptives.
          You may re-submit another application following this period should your patient continue to meet the Program’s criteria.

A tracking number will be assigned by the SOGC upon confirmation of your order. ______________-______ is your tracking number.

                                     FOR PHYSICIAN’S OFFICE USE ONLY
Please complete and save this portion for your office file AFTER you fax the form to toll free number - 1-866-888-PILL (7455).
Patient’s Name: _____________________________________________________________________________________________
Date of Birth: ________________________________________ File Number: __________________________________________
                    Compassionate Contraceptive
                    Assistance Program
                                                                                                                      780 promenade Echo Drive, Ottawa, Ontario K1S 5R7
                                                                                                                         Tel/Tél. : 1 800 561-2416 or/ou (613) 730-4192
                                                                                                                           Fax/Téléc. : (613) 730-4314 www.sogc.org




When patients can’t afford birth control
When a patient’s financial hardship becomes a barrier in obtaining contraceptives,      Contact the SOGC at (800) 561-2416 for more detailed information on the
health care providers can turn to the Compassionate Contraceptive Assistance            Program. Additional forms are available from your Bayer, Janssen-Ortho, Organon
Program to receive free prescriptions. Administered by the Society of Obstetricians     and Wyeth representatives, the SOGC National Office and SOGC Website.
and Gynaecologists of Canada (SOGC), the Program ensures that access to
                                                                                        Please use samples for the purposes for which they were intended – to
contraception is not denied because of a lack of funds.
                                                                                        demonstrate the correct sequence to patients and to provide immediate access
A patient is eligible for compassionate supplies in the event that she is not covered   to contraception. Also encourage dual protection when appropriate. The
by a private insurance plan or government assistance and requires more than a           majority of women starting the use of contraceptives would benefit from using
demonstration sample because she is unable to pay for her medication.                   a contraceptive method in addition to the condom to protect them from sexually
To obtain compassionate supplies, health care professionals are required to fax the     transmitted infections. The need to attend a pharmacy shortly after their first
duly completed “Request Form” to the toll-free fax line (1-866-888-PILL). Requests      office visit is one way to encourage them or their partners to purchase condoms
are then filled by the participating manufacturers and delivered to your office.        at the time the prescription is filled.




Program Registration Form
                FAX THIS FORM TO TOLL FREE NUMBER 1-866-888-PILL (7455)

   Registration Form
   Last Name: __________________________________________________ First Name: ___________________________________
   Designation:          MD            RN          NP           RM                        E-mail: _______________________________________
   Clinic Name: ________________________________________________________________________________________________
   Office Address: ______________________________________________________________________________________________
   City: ________________________________________________________ Province: ________ Postal Code: _________________
   Tel: (________) _______________________________________________ Fax: (________) _______________________________
   Delivery instructions (ex: hours of operation, contact person, etc): ___________________________________________________________
   ____________________________________________________________________________________________________________



   ID Number
   For your order to be processed we must have your signature on file for the current period.
   Licence Number: ____________________________________________________________________________________________

   Physician’s Signature: __________________________________________ Date: _________________________________________