Application for Free AstraZeneca Medicines
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AZ&Me is a trademark of the AstraZeneca group of companies.
©2020 AstraZeneca. All rights reserved. US-37556 2/20
I GIVE my doctor, AstraZeneca, and the Program administrator and their employees, agents, and contractors
permission to verify my information to make sure it is true and complete; contact me by mail or phone about
the Program and about other products, programs, or services that might interest me or for which I may be
eligible; contact me in order to ensure that I have received the medicines sent by the Program.
I PROMISE that all the information in this application, including all copies of documents proving my income,
is true and complete; I am authorized to sign this application; I do not have any assistance or insurance that
would help pay for my medicines (other than Medicare, if applicable); I will contact the Program if any of my
information about my prescription drug coverage or insurance changes.
I UNDERSTAND that the Program will only use my information to decide if I qualify to participate in the
Program; administer or improve the Program; communicate with insurance plans, including Medicare plans;
share my information with the Centers for Medicare and Medicaid Services.
I UNDERSTAND that I may be required to apply for prescription assistance through a government
assistance program to maintain eligibility in the Program.
I UNDERSTAND that I can call 1-800-292-6363 at any time to withdraw from the Program and/or
cancel my permission to use my information. I can visit www.globalprivacy.astrazeneca.com to review
AstraZeneca’s Privacy Notice.
I UNDERSTAND that the Program can request more information from me at any time; AstraZeneca can
change or stop the Program at any time or for any reason.
I UNDERSTAND that once my information has been disclosed to my doctor, federal privacy laws may no
longer restrict its use or disclosure, but the Program will only use my information as described in this form.
I MAY refuse to sign this authorization form and if I refuse, my eligibility for health plan beneﬁts and
treatment by my healthcare provider will not change, but I will not have access to the Program.
I GIVE the Program, and the Program administrators, permission to contact the person named below with
follow-up questions about my application (this only applies if someone completed this application for you).
This authorization form will be effective for 1 year unless it expires earlier by law or I cancel it in writing. I
have a right to receive a copy of this form after I have signed it.
Signature of Applicant or Parent/Legally Authorized Representative. If patient is a minor,
parent or legally authorized representative should sign here.
Relation to Patient: n Patient n Parent/Legally Authorized Representative of Patient
If someone helped you with this application and you want them to answer questions for you, please give
us their name and phone number:
Helper’s Name:______________________________________Helper’s Phone: ( _____ ) ____________
Questions? Call 1-800-292-6363
Monday–Friday, 9:00 am to 6:00 pm ET
or visit www.azandmeapp.com