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                                                                                 2524 Kirk Avenue
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                                                                                 Baltimore, MD 21218
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                                                                                 (Tel) 410-821-9262
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                                                                                 (Fax) 410-821-9265
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                 MEDBANK of Maryland, Inc.
WHAT DOES MEDBANK DO?
MEDBANK works with over 100 pharmaceutical companies. These pharmaceutical companies give
many of the drugs they make to patients at no charge (a few have a very small charge of $5) to patients
who are below a certain income level. The application and income level is different for each company.
These drug companies require proof of the patient’s income be attached to all applications. MEDBANK
is a non-profit organization that gathers all the required information from the patient and his or her
doctor, completes the applications and sends them to the drug companies for approval.

All data Collected by MEDBANK is treated as private and confidential. The patient must agree to share
their private information with the pharmaceutical companies to obtain their free medications.

WHAT HAPPENS NEXT?
If the drug company approves the patient, in most cases they send a three-month supply of drugs directly
to his/her doctor’s office. The patient picks up his/her medicine at the doctor’s office.

HOW LONG WILL IT TAKE BEFORE I RECEIVE MEDICINES?
From the time MEDBANK receives all of the patient’s paperwork, it will typically take 4-6 weeks
before he/she receives medicines. After applications are completed and sent to the drug companies, it
usually takes the drug companies approximately 4 weeks to review the applications and mail the
medicines to the doctor’s office. MEDBANK has just opened a pharmacy that stocks a limited supply
of medications from several major drug companies. Attached in this packet is the MEDBANK
Pharmacy, Inc. Consent and Release form (page 5 of 6), which covers all Pharmacy-based medications.
Both consent forms (pages 4 & 5) must be signed and returned with your completed packet. Without
your consent and authorization – we cannot process your request. If a patient is taking a medicine that is
made by one of these companies, MEDBANK will mail that medicine directly to the patient’s home
(unless otherwise notified) within 5-7 working days. MEDBANK will be adding medications from
more drug companies in the near future.

AFTER A PATIENT RECEIVES HIS/HER DRUGS, HOW DOES HE/SHE GET A
SECOND SUPPLY?
When a patient picks up a medicine from his/her doctor’s office it is very important that he/she call
MEDBANK (410 821-9262) and report the name of the medicine, the date it was received and how
many monthly supply was received. Every three months a new application must be sent to the drug
company in order for the patient to receive another three-month supply of medicines. MEDBANK will
automatically complete applications every three months if the patient has called and reported that they
received medicines. If a patient does not call, MEDBANK will not know when to redo the application
and the patient will not receive more drugs.


        PLEASE CALL MEDBANK EACH TIME YOU RECEIVE MEDICINE

                             The bridge to brighter days ahead.
                                          www.medbankmd.org

MEDBANK Form.referral pack                                                                    Revised 4/5/2010
                  MEDBANK of Maryland, Inc.

           HOW DO I ENROLL IN THE MEDBANK PROGRAM?

You must first call MEDBANK to see if you may be eligible for the program. (410 821-9262) A
referral packet containing several forms for you to complete and one form for your doctor to complete
will be mailed to you. You must complete:

       1. Page 1-3 of the referral form (every blank must be completed)
       2. Page 4 Patient Consent and Release Form (you must sign in two places on this form)
       3. Page 5 MEDBANK Pharmacy Consent and Release Form (you must sign in two places on
          this form)
       4. 4506 Request for Copy or Transcript of Tax Form (complete 1-5 and check b under #8 and
          sign the form where indicated). This form is verification that you did not file an income tax
          return. It is required by several of the pharmaceutical companies. If you did file an income
          tax return, please do not complete this form.

You must also include copies of proof of income. If you are married, you must also send copies of your
spouse’s income. Proof of income may be one of the following:

       1. If you file income tax, a copy of your most recent tax return (year 2002)
       2. If you do not file income tax, a copy of your Social Security Award letter for 2009 and or
          pension statements
       3. If you do not have your awards letter, you may send a copy of your most recent bank
          statement showing direct deposits of your social security check or pension income.
       4. If you are working and your income is from wages earned, you must send copies of your pay
          stubs from the last three months.

The drug companies require these specific documents as current proof of income. MEDBANK must
attach copies of your income to the applications we send to the drug companies. Without complete
proof of income we cannot process your applications.

Take your completed pages 1-5, Form 4506, copies of your proof of income and page 6 with the list of
medicines attached, to your doctor’s office. Your doctor’s office must complete page 6.

Ask your doctor’s office to complete page 6 and fax or mail all of the information to us TOGETHER.
Fax#410 821-9265




                           The bridge to brighter days ahead.
                                         www.medbankmd.org
                PLEASE READ
     IMPORTANT INCOME INFORMATION




IF YOU HAVE APPLIED FOR MEDICAID OR MARYLAND ADULT
PRIMARY CARE (PAC) AND HAVE BEEN TURNED DOWN, YOU
MAY APPLY FOR MEDBANK. IF YOU HAVE NOT BEEN ACCEPTED
INTO A STATE OR FEDERAL PROGRAM YOU MAY ALSO APPLY.




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                      www.medbankmd.org
                 MEDBANK of Maryland, Inc.

Physician/Prescriber Instruction for submitting a referral for
medications



The physician/prescriber must complete page 6 of the referral form. A formulary of medications is
attached for your convenience. Only brand name drugs can be obtained from the patient assistance
programs and/or the MEDBANK Pharmacy.

The patient must complete pages 1-5 of the referral form and the 4506 tax form (if they do not file
income tax) They must also provide proof of their income and their spouse (if applicable) Acceptable
documents that may be used as proof of income are described in the patient’s instructions.

You may fax all information to MEDBANK at 410 821-9265 or you or your patient can mail the
information to us at:
                               MEDBANK of Maryland, Inc,
                               2524 Kirk Avenue
                               Baltimore, MD 21218
When faxing or mailing information, please be sure to include:

                             1. Pages 1-6 of the referral form
                             2. Tax form 4506
                             3. Complete proof of income



                REFERRALS WITH MISSING INFORMATION
                                          CANNOT
                                       BE PROCESSED




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                                         www.medbankmd.org
                                                                   Page 1 of 6
                                                    Patient Questionnaire
 PRINT OR                                        NEW MEDBANK Patient Only
 TYPE ONLY
                                     Phone: 410-821-9262                           Fax: 410-821-9265


What is your…
     Last name?
     First name?
     Middle name?
     Phone number?
     Street address?
     Apartment number?
     City?
     State?
     Zip code?
     Maryland County?
     E-mail address?
     Date of birth?
     Social Security Number?
     Primary language spoken?                 English             Spanish       Other:
     Gender?                                  Male                Female
     Race?                                    African American                   Asian      Hispanic
                                              American Indian                    Caucasian  Other
     Marital Status?                          Single              Married       Widowed  Separated  Divorced

How many people live in your household?
How many people do you claim as dependants on your Tax Returns?
Does anyone claim you on his or her Tax Returns?

Who is your primary care provider or family doctor?
What is the name of his/her private practice/clinic/hospital?
What is his/her phone number?

How did you hear about MEDBANK?
Are you a US Citizen or legal resident?                    Yes           No




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D:\Docstoc\Working\pdf\a11e9878-4346-4762-acc5-394459658703.doc                                                     Revis
                                     Patient Questionnaire
                                               (Page 2)

Do you receive money from any of the following? If yes, please indicate how much you receive each
month. If you receive income from a source not listed below, please specify the source under “Other.”
    Supplemental Social Security        No        Yes     Monthly Amount         $
    Disability                          No        Yes     Monthly Amount         $
    Pension                             No        Yes     Monthly Amount         $
    Unemployment                        No        Yes     Monthly Amount         $
    Social Security                     No        Yes     Monthly Amount         $
    Alimony or Child Support            No        Yes     Monthly Amount         $
    Salary or wages                     No        Yes     Monthly Amount         $
    Other:                              No        Yes     Monthly Amount         $
                                        No        Yes     Monthly Amount         $

Please indicate if you have any of the following medical expenses. If you do, please indicate how much
you pay each month. If you have other medical expenses, please specify them under “Other.”
    Prescription Medications            No        Yes     Monthly Amount         $
    Lab Fees                            No        Yes     Monthly Amount         $
    Office Visits                       No        Yes     Monthly Amount         $
    Other:                              No        Yes     Monthly Amount         $
                                        No        Yes     Monthly Amount         $

Do you have any of the following assets? If yes, please indicate their current value. If you have any
assets not listed below please specify them under “Other.”
    Stocks and/or Bonds                 No        Yes     Current Value          $
    Certificates of Deposit (CDs)       No        Yes     Current Value          $
    Checking Account                    No        Yes     Current Value          $
    Savings Account                     No        Yes     Current Value          $
    Individual Retirement Accounts
    (IRAs)                              No        Yes     Current Value          $
    Annuities                           No        Yes     Current Value          $
    Other:                              No        Yes     Monthly Amount         $
                                        No        Yes     Monthly Amount         $
                                         Patient Questionnaire
                                                (Page 3)

Please complete the following information about your health insurance.
     Primary Insurance Policy:                                 Policy Number:
     Secondary Insurance Policy:                               Policy Number:
     Do you have insurance that covers Prescriptions?       Yes      No
        If yes, how much is covered per year?   $
        Have you reached this limit?             Yes       No      If yes, when?
        When will you have coverage again?
     Do you have Medicare Coverage?         Yes     No       Medicare Number:
     Do you have Medicaid Coverage?         Yes     No
     Do you have Veterans Assistance?       Yes     No
     Do you use any pharmaceutical company discount cards?         Yes      No
        If yes, which one(s)?

As far as you know, are you allergic to any medications?  Yes        No
     If yes, please list:

When was your last…
     Office Visit?               Date:                  Reason:
     Stay in the hospital?       Date:                  Reason:
     Emergency room visit?       Date:                  Reason:

Optional: Please complete the following information if there is an alternative contact (family member,
social worker, etc.) that we should communicate with.
     Last name:
     First name:
     Street Address:
     Suite/Apartment Number:
     Phone Number:
     City:
     State:
     Zip code:
     Relationship to Patient:
     Should this be our primary contact?       Yes      No
        If yes, please indicate why:


Personal information received will be treated with confidentiality and viewed only by MEDBANK personnel.
    The patient may inspect information we have on file at any time and request that changes be made.
                                                  Page 4 of 6
PRINT OR                 Physician/Prescriber Referral for Medications
TYPE ONLY                       NEW MEDBANK Patient Only
                        Phone: 410-821-9262                         Fax: 410-821-9265

                               PATIENT CONSENT AND RELEASE FORM

                                       EXCHANGE OF INFORMATION

 I give permission to authorized representatives of The Maryland Medbank Program (MEDBANK) to inspect my
 medical records whenever necessary to obtain pertinent information needed to solicit medications on my behalf
 from companies that manufacture or provide medications through patient assistance programs. I also authorize
 MEDBANK to discuss me and my medical needs with my physician/prescriber when necessary. Additionally, I
 give MEDBANK permission to verify my income through the Dept. of Social Services, Social Security
 Administration, my employer, Veterans Administration or any other company, business, or organization from
 which I receive income. 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 such.

 I agree that a copy of this form can be accepted as a valid consent to share information.

 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 information about me that they need.


 Date Of Birth:                                Social Security Number:
 Address:
 Full Printed Name Of Patient:
 Signature:                                                      Date:


                                  PATIENT SIGNATURE AUTHORIZATION

 I authorize representatives of The Maryland MEDBANK Program to sign forms on my behalf for the
 purpose of soliciting medications on my behalf from companies that manufacture or provide
 medications through patient assistance programs. This signature authorization is good as long as
 MEDBANK is assisting me or until I revoke such.

 Full Printed Name Of Patient:
 Signature:                                                      Date:




  PLEASE CALL MEDBANK EACH TIME YOU RECEIVE MEDICINE



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                                               www.medbankmd.org
                                                         Page 5 of 6
 PRINT OR                    Physician/Prescriber Referral for Medications
 TYPE ONLY                          NEW MEDBANK Patient Only
                             Phone: 410-821-9262                       Fax: 410-821-9265

PHYSICIAN/PRESCRIBER COMPLETES THE FOLLOWING:
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

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




Please indicate below if you wish correspondence or medications directed to an alternate address:
Direct all Physician/Prescriber correspondence to:
Ship Medications to:
                                              Prescriber’s above address or other office location.



Prescriber’s Signature:                                                      Date:

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


                                The bridge to brighter days ahead.
                                                    www.medbankmd.org

				
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