Fill - Free fillable Bi Cares Pap Application-fillable BI Cares PAP Application PDF form

BI Cares Patient Assistance Program

P.O. Box 5520, Louisville, KY 40255

Hours of Operation:

Monday – Friday

8:30

– 6:00

05/2019

Phone: 1-800-556-8317 Fax: 1-866-851-2827

BI Cares Patient

Assistance Program

Who

is eligible?

All applications are reviewed in accordance with BI Cares program eligibility criteria. To be

eligible, you must:

❑ Be a resident with a physical address within the United States or US Territory

❑ Have one of the insurance coverage circumstances outlined below:

o No health coverage

o Not enough coverage to obtain the medication

(eligible drugs are listed below)

❑ Not have access to alternate sources of coverage or funding for your medication

❑ Meet household income guidelines established by BI Cares

Wha

t information is needed to submit an application?

The following items should be submitted to the BI Cares Patient Assistance Program for the

application to be considered complete:

❑ Complete Sections 1-4 including signatures

❑ Have a Healthcare Provider complete Sections 5 & 6 including an original signature

at medications are eligible?

The following medications are eligible for the BI Cares Patient Assistance Program:

o Aptivus

o Atro

vent

HFA

o Combivent

o Glyx

ambi

o Jar

diance

o Jentadueto

Jentadueto

o Pradaxa

o Sp

iriva

Handihaler

o Sp

iriva

Respimat

o Stiolto

Respimat

o Str

iverdi

Respimat

o Sy

njardy

& Synjardy

o Tradjenta

o Vir

amune

Patient Assistance Program Please Print Clearly

Application In Black or Blue Ink

BI Cares Patient Assistance Program

Phone: 1-800-556-8317

Hours of Operation:

Monday – Friday

8:30

– 6:00

05/2019

Application Page

1 of 4

Section 1: Patient Information

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Note: Delivery will be to patient’s address unless otherwise indicated. Aptivus

& Viramune

XR will

be shipped to the Healthcare Provider.

Preferred Daytime Phone Number *:

( ) –

I authorize Boehringer Ingelheim Cares Foundation, Inc. (“BI Cares”) and its affiliates, agents,

representatives and service providers to use auto-

dialers, prerecorded messages, artificial voice

messages and messages to contact me at the number I provided above and that these calls may be

informational and marketing related and mention the name of BI Cares and of services or products

offered by BI Cares, including Boehringer Ingelheim drug products, details about my insurance coverage

and my doctor’s name. I understand I am not required to consent to being contacted by auto-dialers,

prerecorded messages, artificial voice messages and text messages as a condition of enrollment in BI

Cares and if I do not consent, I will not provide my phone number. Standard message and data rates

may apply.

Please Send me Text Notifications on Program & Shipment Statuses: Yes No

If Yes and if you would like to receive the text notifications on a different phone number than above,

please provide the preferred phone

number for text notifications:

( ) –

Date of Birth (MM/DD/YYYY):

/ /

Gender (Select One):

Male

Female

Last 4 Digits of SSN:

Note: This is Required for Income Verification

Preferred Language (Select One): English Spanish Other:

Section 2: Patient Financial Information

How many people live in your household (including yourself)?

What is the total household income for a year?

Total patient household assets (excludes first home and car)

I understand that to qualify for free product my adjusted gross income must meet the Program income

guidelines and that my income will be validated through Experian’s household income assessment tool

(“Experian”) based on the information I provide. If my income cannot be verified through Experian, BI Cares

will request documentation from me such as my IRS 1040 form or other proof of income to verify my financial

information. I agree to provide such information in a timely manner. BI Cares may request information from

me, my health care provider or my insurance company to verify my insurance information. I understand that

any free product provided to me through BI Cares is contingent upon my meeting eligibility criteria; and that

BI Cares reserves the right to make an independent determination of my financial and medical need.

Patient (or Authorized Representative) Signature

Date

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Patient Assistance Program Please Print Clearly

Application In Black or Blue Ink

BI Cares Patient Assistance Program

Phone: 1-800-556-8317

Hours of Operation:

Monday – Friday

8:30

– 6:00

05/2019

Application Page

2 of 4

First Name:

Last Name:

Section 3: Insurance Information

Select Yes or No

Have you received disability payments from Social Security for more

than 24 months? ………………………………………………………………………………

Yes

Have you received a denial letter from Medicare Low Income Subsidy?....

Yes

If yes, please attach a recent copy of this letter along with your application.

Do you have Medicare Part D or Medicare Advantage? ...……………………..

Yes

Do you have Medicaid? ……………………………………………………….................

Yes

Do you have prescription drug coverage from a commercial or private

health insurer? ……………………………………………………………………………..….

Yes

Do you receive Veterans Affairs Benefits? ……………………….…………………..

Yes

Section 4: Patient Attestation & HIPAA Authorization

Patient Att

estation

The information you, the Patient, provides as part of this BI Cares Patient Assistance Program application

(“Application”) will be used by Boehringer Ingelheim Cares Foundation, Inc. (“BI Cares”) and its affiliates,

agents, representatives and service providers, including Experian, to:

(1) process this Application and verify the information contained in this Application,

(2) administer, analyze, and improve the BI Cares Patient Assistance Program (“Program”),

(3) improve and tailor our products and services to better serve you,

(4) communicate with you about your experience with the Program, and/or

(5) send you materials and other helpful information and updates relating to BI Cares programs

(“Services”).

By signi

ng below, you, the Patient, attest and certify that:

 The information provided in this Application and any additional information provided as part of

the Application process is current, complete, and accurate to the best of your knowledge.

 You cannot afford the medication requested and (1) have no coverage or (2) have no coverage for

this medication or (3) have coverage for the medication but have an out-of-pocket expense you

cannot afford.

 You will not seek reimbursement from any insurer or government program for any medication

dispensed from the Program.

 You will notify the Program immediately if the medication requested is no longer medically

necessary for your treatment or if your insurance or financial status has changed.

[Conti

nued on Next Page]

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Patient Assistance Program Please Print Clearly

Application In Black or Blue Ink

BI Cares Patient Assistance Program

Phone: 1-800-556-8317

Hours of Operation:

Monday – Friday

8:30

– 6:00

05/2019

Application Page

3 of 4

First Name:

Last Name:

In addition, by signing below, you, the Patient, understand and agree that:

 Any medication supplied as a result of this Application is for your use only, and shall not be sold, traded,

bartered, transferred, returned for credit. No claims involving this medication shall be submitted to any

third party (such as Medicare, Medicaid, Veterans Affairs or any other public programs) for

reimbursement.

 Completing this Application does not guarantee that assistance will be provided to you.

 The information provided in this Application is subject to random audits and verification. During such

audits and verification processes, you may be asked for additional supporting documentation.

 BI Cares may change this Program at any time and reserves the right to terminate your enrollment at

any time due to lack of eligibility or related factors.

 Additional information may be requested to process this application including verification of your

income through sources such as Experian.

 The medication made available to you under this Program may be denied if you do not fully cooperate

with efforts made to verify the information provided in this application, or if you do not take steps to

secure other forms of payment for your medication after being notified of other programs for which you

may be eligible.

 BI Cares is not obligated to verify any of the information contained in this Application or to confirm

other medications that you are taking.

HIPAA Authorization

By signing below, you, the Patient, hereby authorize:

 Your physicians, health care providers, pharmacy providers, and health plans to disclose to BI Cares

and its affiliates, agents, representatives and service providers, including Experian, (“Recipients”) your

individually identifiable health information, which may include information related to your medical

condition, treatment, care management, health insurance, medication history, and prescriptions

(“Health Information”).

 The Recipients to access, obtain, use, disclose, receive, and maintain your Health Information for

purposes of processing this Application, verifying the information provided in this Application, assisting

in the identification of, or determining eligibility under, other patient assistance resources, and

conducting the additional Services described above.

In addition, by signing below, you, the Patient, understand and agree that:

 This authorization is voluntary, but if you do not sign it, you will not be able to participate in the

Program. Your physicians and healthcare providers may not condition the provision of your treatment

on your signing this authorization.

 Information released under this authorization may no longer be protected by state and federal law.

 You may withdraw your authorization at any time by mailing a written withdrawal to BI Cares at the

address below, however, such withdrawal will not have an impact on any actions that have already been

taken in reliance on this authorization.

 If you do not withdraw your authorization, this authorization will be in effect for one year from the date

of enrollment if approved for the program.

 Your pharmacy may receive compensation in exchange for reports containing your information.

Patient (or Authorized Representative) Signature

Date

Mail or Fax the Complete Application to:

BI Cares Patient Assistance Program

P.O. Box 5520, Louisville, KY 40255

Fax: 1-866-851-2827

Print Form

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Patient Assistance Program Please Print Clearly

Application In Black or Blue Ink

Prescriber Signature (Original – Stamps NOT ACCEPTED)

Date

Application Page 4 of 4

Section 5: Prescriber Information

Prescriber Name:

NPI:

Specialty:

SLN #:

SLN Exp. Date:

Site/ Facility Name:

Office Contact Name:

Address

City:

State:

Zip Code:

Office Phone:

Office Fax:

Section 6: Prescription & Medication Information*

First Name:

Last Name:

Date of Birth:

/ /

Product Name/ Strength:

90 days

Directions:

1 2 3

Medication Allergies?

Days Supply:

Refills (Select One): .

Yes No

If Yes, please list all drug allergies:

Current Medications (please list):

* A separate prescription form may be attached to this application and a separate form should be attached if

required by federal and state law.

The information you, the Prescriber, provides as part of this BI Cares Patient Assistance Program application

(“Application”) will be used by Boehringer Ingelheim Cares Foundation, Inc. (“BI Cares”) and its affiliates, agents,

representatives and service providers to (1) process this Application and verify the information contained in this

Application, (2) administer, analyze, and improve the BI Cares Patient Assistance Program (“Program”), (3) improve

and tailor our products and services to better serve you, (4) communicate with you about your experience with the

Program, and/or (5) send you materials and other helpful information and updates relating to BI Cares programs

(“Services”).

By signing below, you, the Prescriber, attest and certify that:

 The information provided in this Application and any additional information provided as part of the Application

process is current, complete, and accurate to the best of your knowledge.

 To the best of your knowledge, the patient identified in this Application cannot afford the medication requested

and (1) has no coverage or (2) has no coverage for the medication or (3) has coverage for the medication but has

an out-of-pocket expense he/she cannot afford.

 You will not seek reimbursement for any medication dispensed from the Program.

 You will notify the Program immediately if the medication requested is no longer medically necessary for this

patient’s treatment or if you become aware that your patient’s insurance or financial status has changed.

 You have a signed copy on file of your patient’s current and completed HIPAA Authorization, or any other

authorization or consent required by law, so that you may share patient health information with the Program,

including BI Cares and its affiliates, agents, representatives and service providers.

In addition, by signing below, you, the Prescriber, understand and agree that:

 Any medication supplied as a result of this Application is for the use of the patient named on this form only,

and shall not be sold, traded, bartered, transferred, returned for credit. No claims involving this medication

shall be submitted to any third party (such as Medicare, Medicaid, Veterans Affairs or any other public

programs) for reimbursement.

 Completing this Application does not guarantee that assistance will be provided to your patient.

 The information provided in this Application is subject to random audits and verification.

 BI Cares may change this program at any time and reserves the right to terminate your patient’s enrollment at

any time due to lack of eligibility or related factors.

Fax the Complete Application to:

1-866-851-2827

05/2019

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