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Patient Assistance Forms


Patient Assistance Forms document sample

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									Patient                                                                      Helping you receive
                                                                             the medication you
Medication                                                                   need without the
Assistance                                                                   hassle or expense

Paying for prescription drugs can be very costly, especially if you have no insurance or make little money
to pay for expensive medication.

Patient Medication Assistance will locate free medication for you. Hundreds of Pharmaceutical
companies give out free medications under patient assistance programs. Most pharmaceutical companies
do not advertise or widely promote these programs. Patient Medication Assistance will help determine
your eligibility for the patient assistance programs and assist you with completing the proper paperwork
required by each pharmaceutical company.

Each pharmaceutical company has its own requirements. In most cases to be eligible for free medication
applicants must show that:
   * You do not have prescription drug coverage.
   * Your income is low enough that paying for prescription drugs is very difficult.
   * Approximate income for individuals $24,000 or less; 2 people in household $40,000 or less.
   * You do not qualify for Medicaid or other government assistance programs.
Program Features:
  * Mail you completed pharmaceutical applications that only require signatures.
  * Check your forms for completeness and eliminate any unnecessary paper work.
  * Keep track of any changing eligibility requirements.
  * Keep a current data base of almost 200 pharmaceutical companies.
  * Personal service M-F 8:00 a.m. to 5:00 p.m.

How it works
1) Please complete your Patient Information and Medication forms and return with payment in provided
    envelope. Also choose delivery option.
2) Once we receive your information, we will mail you completed pharmaceutical applications for your
    signature and review.
3) Sign all applications and return in postage provide envelope.
4) We will work closely with your doctor’s office to have their portion completed.
5) Patient Medication Assistance will review your pharmaceutical application for accuracy, and then
    forward all applications to the appropriate pharmaceutical company.
6) After the pharmaceutical companies approve and process your application, you should expect to start
    receiving your medications in 2 to 4 weeks.
7) Patient Medication Assistance will track your medications for renewal and complete all applications
    needed to reapply for your medications.

      Customer Service M-F 9:00 a.m. to 5:00 p.m. 1-866-353-9377 or 317-838-0671
                     For more information please visit our website
Patient                                                             Helping you receive
                                                                    the medication you
Medication                                                          need without the
Assistance                                                          hassle or expense

Patient Medication Assistance charges for the administrative service of managing and
tracking prescription medications received with our assistance. The medications
themselves are free from the pharmaceutical companies. We keep a data base with more
than 200 pharmaceutical companies that offer free medications, however Xubex and RX
Outreach charge a small co-pay or delivery charge.

Monthly Service Fee

We charge a $32.00 monthly service fee to manage your patient assistance programs. We
will also work with your doctor’s office and pharmaceutical companies to help ensure fast
and accurate refills of your medications.

We bill our clients $32.00 monthly regardless of the number of medications. Your service
is pre-paid each month and you may cancel at any time with a 30 day written notice.

    In January you begin receiving 5 medications (you pay $32.00 per month)
    In February you add additional medication (you still pay only $32.00 per month)

                 You should receive your first statement in 30 to 45 days.

Money Back Guarantee

We do not accept all applications. If we feel based on the information you provide, that
you will not qualify for assistance, you will receive a full refund within 10 business days.

Over 99% of the applications we send to the pharmaceutical companies are approved. If
for any reason you are denied assistance for all of your medications, we will refund all
service fees paid within 10 business days of notification.

Customer Service

Once we receive your completed application, you will be assigned a customer care
representative. Your representative will complete all necessary applications and work
closely with your doctor’s office. Your representative is available to assist you
Monday –Friday 9:00 a.m. to 5:00 p.m. (Eastern Standard Time)
                            Customer Service 1-866-353-9377
                                    PATIENT INFORMATION FORM

Patient First Name                                     M.I.    Patient Last Name

Full Mailing Address (Include street name, apartment number, P.O. Box number)

City                                                                State                     Zip Code

             -                  -                                             -           -
Area Code         Telephone Number                                  Date of Birth (MM-DD-YYYY)

             -             -
Social Security Number                               Female    Male         Medicare          Medicaid

                                                       Are you Disabled?            YES          NO
 Married         Single    Divorced      Widow

Do you currently have prescription drug coverage?                       YES         NO

Total number of dependents, including yourself, in the household

Did you file taxes last year?                  YES             NO

Your gross monthly household income $___________________________
                ( If you are married, you must include both incomes.)

Please list all sources of income:_________________________________________________________
                                             (Example S.S, Disability, Wages, etc.)

                     Please enclose proof of income for all living in household.
                  Example: Social security statement, pay stub, most recent taxes etc.
                           PATIENT MEDICATION FORM

                                                                  Quantity Doctor's              Phone
Internet              Name of Medication                 Strength Per Day   Name                Number

EXAMPLE                     Synthroid                      40 mg        2         Joe Jones   (317) 123-4567











                       Comments or additional medications please use back of page.

     Please print correct spelling of medication and do not send prescriptions with application.

                          Please enclose a check with completed application to:
                                     Patient Medication Assistance
                                            204 East Main St.
                                           Plainfield, IN 46168
Patient                                                                                Helping you receive
                                                                                       the medication you
Medication                                                                             need without the
Assistance                                                                             hassle or expense

Please note, we do not handle or ship medications and are not affiliated with any pharmaceutical company or drug
manufacturer. We are a fee-based service that will assist you in obtaining medications through patient assistance
programs. For your monthly service fee we provide the following:

        Locate and complete pharmaceutical applications to apply for drug assistance.
        Full customer support – Available 9:00 a.m. to 5:00 p.m. Monday to Friday.
        Complete management of multiple Drug Assistance Programs.
        Provide postage cost related to your pharmaceutical applications.
        Mail all applications to your doctor for approval and attach any necessary documents.
        Review all applications for accuracy before forwarding to the pharmaceutical company.
        Track your medications for renewal and complete appropriate applications (usually every 90 days).
        You may add new medications at any time with no increase in your monthly service fee.

 Our goal is to help you receive your medications through Drug Assistance Programs
                                        with little hassle or expense.

By signing below I understand that: 1) Each pharmaceutical company must approve my application, and some
medications my not qualify. 2) I will receive a full refund if it is determined that I am ineligible for Drug Assistance
Programs. 3) I am paying Patient Medication Assistance $32.00 per month for locating, completing pharmaceutical
applications, and tracking medications received with their assistance. 4) I am not paying for pharmaceutical
applications and most can be obtained for free. 5) I will be assigned a customer service representative that will
manage my drug assistance applications and perform administrative work to receive drug assistance. 6) Patient
Medication Assistance will be in contact with my doctor’s office to have their portions of pharmaceutical
applications completed. 7) Any delays at my doctor’s office may result in a delay in receiving medications. 8) Each
pharmaceutical company determines where my medications are shipped; in most cases my medications will be
shipped to my doctor’s office in a 90-day supply. 9) Once the pharmaceutical companies approve my applications,
it normally takes 2 to 4 weeks to receive my medications. 10) Patient Medication Assistance will automatically
send me applications to re apply for drug assistance approximately 45 days before I am out of medicine. 11)
Patient Medication Assistance is not liable for wrong medications shipped by drug manufacturers or any time I run
out of medication received through drug assistance programs. 12) If I run out of medications I should purchase my
medication while waiting for drug assistance. 13) I may cancel at any time with a 30 day written notice.

_______________________________                        ______________________________               ___________
        Patient signature                                          Printed name                      Date
Patient                                                                                       Helping you receive
                                                                                              the medication you
Medication                                                                                    need without the
Assistance                                                                                    hassle or expense
                                               Delivery Options
Standard delivery- Patient Medication Assistance will process your application within 72 hours and
forward all applications standard mail to address provide. You should receive your completed
applications in 6 to 10 days.

Priority delivery- Patient Medication Assistance will process your application the same day and Priority
mail the completed applications to the address provided. You should receive your applications in 2 to 3

Overnight delivery- Patient Medication Assistance will process your application the same day and
overnight the completed pharmaceutical applications to the address provided for signatures. We will
provide a pre-paid return overnight envelope and process your applications the same day with priority
delivery to each pharmaceutical company. You could receive your medications in as little as 10 days.

                                                 Other Services
Premium Membership- Our premium service will help eliminate the need for you to sign refill
applications. Patient Medication Assistance will print approximately one full year of applications that
require your signature. You will need to review the applications and sign in the yellow highlighted areas.
After we receive the applications from you, we will hold them in your file and use as needed throughout
the year. By signing refill applications now, you can help ensure faster refills on your medications.

My Medical Journal- My medical Journal is an easy to use health record. My Medical Journal allows
you to keep track of your medications, hospital visits, and medical history. Your doctor also documents
each visit directly in the journal, such as: blood pressure, weight, pulse, Office test, and doctor’s advice or
actions required. My Medical Journal allows you to have quick and convenient access to your medical
records to share with doctors or family members.

                                               Delivery Options
 Standard delivery- Please enclose a check for $32.00
 Priority delivery- Please enclose a check for $59.00 (Includes first months payment.)
 Overnight delivery- Please enclose a check for $99.00 (Includes first months payment.)

                                                Add on services
 Premium Membership- Please enclose a check for $49.00 plus Delivery Option
 My Medical Journal- Please enclose a check for $19.00 (Journal Only)

Delivery Option _____________plus Add on Service _____________Total enclosed ___________
  (Please write $32.00, $59.00, or $99.00)   (Please write $0 no add on, $49.00, or $19.00)   (Add both numbers together)
                                                                                    Helping you receive
Patient                                                                             the medication you
Medication                                                                          need without the
                                                                                    hassle or expense
We recommend automatic monthly bank draft. By signing up for automatic bank draft,
you will not have to mail a check for you monthly service fee or worry about late fees. On
your due date, we will automatically deduct your $32.00 monthly service fee from your
bank account. It’s easy to get started and saves you time and money over writing a check
each month. Please sign up for automatic bank draft now by completing the bottom
portion of this page.

As a convenience to me, I_____________________________, request and authorize
Patient Medication Assistance Inc. of Avon, Indiana to withdrawal my monthly service
fee, in the amount of $32.00. I agree that my rights in respect to each payment shall be the
same as if drawn by me and signed by me. This authority is to remain in effect until
revoked by me in writing 20 days before next draft. I agree that you shall be protected in
honoring any such check or electronic debit. Patient Medication Assistance will only
charge my account $32.00 each month on my normal due date.

                                  Please include a voided check

Signature ______________________________________Date___________

Requested Draft Date             (please circle) 10th          20th 30th of each month

       Patient Medication Assistance Inc. 8103 E. US Hwy. 36 #245, Avon, Indiana 46123 Phone 1-866-353-9377

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