Fillable BMSPAF Enrollment Form.83d9b86a (Bristol Myers Squibb Patient Assistance Foundation)

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BMSPAF Enrollment Form.83d9b86a (Bristol Myers Squibb Patient Assistance Foundation)

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Page 1 of 4
NOUS2002987-01-01 09/20
ELIQUIS
®
, NULOJIX
®
, and ORENCIA
®
are trademarks of Bristol-Myers Squibb Company.
Phone: 800-736-0003
Monday to Friday, 8:00 AM – 8:00 PM ET
(excluding holidays)
If you are enrolled in the BMSPAF and need continued assistance for the medications above, you can re-apply using this form.
Patient Information
Insurance Information
Household Size & Income
Proof of Income
Out-of-Pocket Prescription Expenses
Sign & Date Patient Agreement
& Consent
Treatment & Prescription Information
Prescriber & Treatment Site Information
Shipping Address (if different)
Sign & Date Prescriber Certification
Attach Prescription
ELIGIBILITY
Applying directly to
the BMSPAF is free.
There is no charge to
submit your application
form.
TO APPLY, COMPLETE THIS FORM AND:
APPLICATION FORM
The Bristol Myers Squibb Patient Assistance Foundation, Inc., (BMSPAF) is a non-profit organization that
seeks to help eligible patients get the following medicines for free:
ELIQUIS
®
(apixaban) NULOJIX
®
(belatacept) ORENCIA
®
(abatacept)
Return it by mail to:
Bristol Myers Squibb Patient Assistance Foundation
PO Box 220769
Charlotte, NC 28222-0769
OR fax it to: 800-736-1611
PATIENT & PRESCRIBER INFORMATION CHECKLIST:
PLEASE NOTE: If requested information is missing from your application, our response to your application
will be delayed.
PATIENTS: COMPLETE SECTION I
PRESCRIBERS: COMPLETE SECTION II, III, IV
These are a few of the eligibility requirements from BMSPAF. Meeting
these requirements does not guarantee you will be accepted.
Please include the following
documents with your
application:
• Proof of household
income (such as federal
tax return, social security
statements)
• Proof of out-of-pocket
prescription expenses
for the household (such
as a pharmacy printout)
See bottom of page 2
for more information.
Page 2 of 4
NOUS2002987-01-01 09/20
ELIQUIS
®
, NULOJIX
®
, and ORENCIA
®
are trademarks of Bristol-Myers Squibb Company.
Phone: 800-736-0003
Monday to Friday, 8:00 AM – 8:00 PM ET
(excluding holidays)
Patient Name
Social Security Number (optional):
Date of Birth:
Gender: Female Male
Patient Address (no PO Boxes):
City:
State:
Zip:
Home Phone:
Cell Phone (optional):
Email Address (optional):
Alternate Contact Name (optional):
Relationship (optional):
Phone (optional):
Allergies (Do not leave blank. If none, write “none”. Attach a list on a separate page if more space is needed):
All Current Medications (Do not leave blank. If none, write “none”. Attach a list on a separate page if more space is needed):
PATIENT INSURANCE INFORMATION – Do you have insurance through any of these providers?
(Check all that apply)
Medicaid
Medicare: Part A Part B Part D Part C/Medicare Advantage
VA or Military
Private Insurance
None
State Assistance Program for Medication
Other:
INSURANCE NAME
PHONE #
ID/POLICY #
Primary:
Secondary:
Prescription Coverage:
(Optional: Attach a copy of both sides of your
prescription insurance card)
ID/Policy #:
RxBIN:
RxPCN:
Number of people living in your home:
(Include yourself, your spouse, and any dependents currently living with you)
TOTAL YEARLY HOUSEHOLD INCOME:
$
OR
TOTAL MONTHLY HOUSEHOLD INCOME:
$
Proof of income may be required: Please provide your most recent federal tax return. If your federal tax return is not available,
please provide as many of the following as available: W2, 1099, pension statement, Social Security statement, at least 2 consecutive
pay stubs.
Medicare Part D recipients: You may be eligible for assistance if you have spent at least 3% of your annual household income on
out-of-pocket (OOP) prescription expenses during the same year for which you need assistance from BMSPAF. For example, if you
are applying for assistance for 2021, please attach 2021 OOP prescription expenses to this application. Your pharmacy can provide
you with your year-to-date OOP expenses. Applications may not be fully processed without proof of these expenses.
Please continue to the next page to read, sign, and date the Patient Agreement & Consent.
Section I: Patient Information
(TO BE COMPLETED BY PATIENT. ALL BOXES ARE REQUIRED EXCEPT WHERE NOTED.)
BMSPAF Case #:
PO Box 220769, Charlotte, NC 28222-0769 | Phone: 800-736-0003 | Fax: 800-736-1611
Page 3 of 4
NOUS2002987-01-01 09/20
ELIQUIS
®
, NULOJIX
®
, and ORENCIA
®
are trademarks of Bristol-Myers Squibb Company.
Phone: 800-736-0003
Monday to Friday, 8:00 AM – 8:00 PM ET
(excluding holidays)
Patient Agreement & Consent
I promise that:
•
All of the information I provided in my application, and other documents or information that I may provide, are
complete and true.
•
If I am approved (enrolled), I agree that I will not be reimbursed for the free medicine from anyone else, including
a prescription insurance program or any other charity. If I have Medicare Part D, I will not count any free medicine
toward my true out-of-pocket costs (TrOOP).
•
If my insurance coverage or income changes in any way, I will immediately notify BMSPAF.
I give my permission to:
•
My insurance providers, healthcare providers, and others helping me apply to this program, to share information
about me with BMSPAF and the companies that BMSPAF uses to administer the program (Administrators).
My information that will be shared includes my personal information in my application,
as well as my health information and records, insurance information, and financial and income information.
•
BMSPAF and its Administrators to use my information, and share it with my healthcare providers, my insurance
company, and other organizations or companies that might be able to help me, so that BMSPAF and its
Administrators may: decide if I am eligible for the program, help me get the free medicine during my enrollment
(if I am eligible), and find out if I may be eligible for, or already enrolled in, another program (including a prescription
insurance plan or another charitable program).
•
BMSPAF and its Administrators to obtain a consumer report on me. My consumer report, and information derived
from public and other sources, will be used to estimate my income as part of the process to decide if I am eligible to
receive free medicine from BMSPAF. Upon request, BMSPAF will provide me the name and address of the consumer
reporting agency that provides the consumer report. I may call BMSPAF at 800-736-0003 for this information.
I understand that:
•
BMSPAF and its Administrators may contact me by phone or other methods to ask for additional information at any
time, even if I am enrolled, so that they can decide if the information on my application is complete and true.
•
BMSPAF and its Administrators may delay, deny, or end my enrollment if my application is missing information or
I do not respond to requests for documents or information.
•
If I am enrolled, BMSPAF will only give me free medicine for a short time and I will have to reapply before my
enrollment ends if I still need help with free medicine.
•
I may not be eligible for free medicine if I have insurance coverage that will pay for my medicine (other than eligible
patients covered under Medicare Part D).
•
I understand that once my information has been disclosed, privacy laws may no longer restrict its use or disclosure.
BMSPAF and its Administrators will share my information as described in this consent form or as required or
allowed by law.
•
I may refuse to sign this consent form and if I refuse, my eligibility for health plan benefits and treatment
by my healthcare providers will not change, but I will not have access to this program.
•
This consent will be effective for 18 months unless it expires earlier by law or I cancel it in writing. I may cancel this
consent at any time by writing to BMSPAF at the address in this application. If I cancel this consent, I will no longer
be eligible for the program and my enrollment will end.
•
I have a right to receive a copy of this form after I have signed it.
•
BMSPAF may change or stop the program at any time without notice.
Print Patient Name:
Patient Signature:
Date:
You must sign
and date to apply.
Page 4 of 4
NOUS2002987-01-01 09/20
ELIQUIS
®
, NULOJIX
®
, and ORENCIA
®
are trademarks of Bristol-Myers Squibb Company.
Phone: 800-736-0003
Monday to Friday, 8:00 AM – 8:00 PM ET
(excluding holidays)
3
Patient Name:
DOB:
Is the patient receiving treatment as an outpatient? Yes No
ELIQUIS® (apixaban)
ORENCIA® (abatacept) SC
Dosage: _________________________________________
Sig: _____________________________________________
Days’ Supply: 90 60 30 Other: ________
Number of Refills: __________________________________
Rx may be written for up to a 1-year supply (refills are subject to eligibility-
period limits). Specify number of refills needed. Shipping limits: Up to a 90-
day supply available.
ORENCIA® (abatacept) IV*
NULOJIX® (belatacept)
*If you are prescribing both ORENCIA SC and IV, please include a
prescription for both.
BSA/Weight: _______________________________
ICD-10 Code: ______________________________
Dosage: __________________________________
Dosing Schedule: ___________________________
_________________________________________
Number of Doses Authorized: ** ________________
**Complete for up to a 4-week supply.
Section III: Prescriber Information
Name:
State License #:
NPI:
Office Name:
Office Phone:
Office Fax:
Office Address (no PO Boxes):
City:
State:
Zip:
Collaborating Physician (if applicable):
Collaborating Physician NPI:
For case-related questions or fax communications, provide the preferred contact information below:
Primary Contact Name/Title:
Primary Contact Phone:
Primary Contact Fax:
Preferred Method of Contact: Phone Only Fax Only Phone and Fax
Section IV: Ship Medication To: (We cannot ship to PO Boxes)
Patient
(For oral medicines only)
Healthcare Provider Office
(Office address listed in Section III)
Other Treatment Site
(Include Treatment Site address below)
Treatment Site Name:
Address (no PO Boxes):
City:
State:
Zip:
State License # of the Shipping Address Location (if different from the State License # noted above):
Prescriber Certification
I certify to the following: (1) Treatment with this medicine for this patient is medically necessary, based on my independent clinical judgment; (2) Information that I
provide to BMSPAF, and in this form, is complete and accurate; (3) I have the authority to disclose this patient's information and I have obtained, if required by HIPAA
or other applicable privacy laws, this patient's authorization; (4) To the best of my knowledge, this patient has no prescription insurance coverage (including Medicaid,
Medicare, or other public or private programs), or is unable to afford the cost-sharing requirements associated with his/her insurance coverage, for this medication;
(5) I will immediately notify BMSPAF if I become aware that this patient’s insurance or income status has changed; (6) I will not submit an insurance claim or other
claim for payment to any third-party payer (private or government), and I will forego any appeal of any denial of insurance coverage, for medication provide d by
BMSPAF for this patient, nor will I count the free medicine towards this patient’s true out-of-pocket costs (TrOOP); (7) Any medication provided by BMSPAF for this
patient will not be resold, nor offered for sale, trade or barter, or returned for credit. I understand that: (1) BMSPAF reserves the right to verify all information provided
by healthcare professionals, suspend participation where inadequate information is provided, and limit enrollment based on available resources; (2) BMSPAF
reserves the right to modify or terminate this program, or recall or discontinue medications, at any time without notice; (3) BMSPAF, and its agents and assignees,
are relying on the certifications in this form. I authorize this prescription.
Prescriber Signature:
Date:
BMSPAF Case #:
PO Box 220769, Charlotte, NC 28222-0769 | Phone: 800-736-0003 | Fax: 800-736-1611
Application must be signed & dated by a
licensed prescriber – No Stamps.
Section II: Prescription - TO BE COMPLETED BY LICENSED PRESCRIBER - MD; OR NP, WHERE
PERMITTED). Same person should also sign this application form (All boxes are required).
Note: NY prescriptions must be on official NY State Prescription Form
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BMSPAF Enrollment Form.83d9b86a (Bristol Myers Squibb Patient Assistance Foundation)

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Completed 7 September 2021

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