Fillable Form 1: cabotegravir / rilpivirine ENROLLMENT FORM

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Form 1: cabotegravir / rilpivirine ENROLLMENT FORM

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Form continued on the following page
1 o f 3
Patient Information
1
First Name Last Name
D.O.B. (mm/dd/yyyy)
Street Address
Apt/Bldg/Fl
City State
ZIP Code
Phone #
M.I.
Email
Sex:
M F
List all current medications, over-the-counter medications, and supplements List all known drug allergies Previous antiretroviral (ARV) therapies
Check box if none
Check box if list is attached
Prescriber Information
2
Street Address City State ZIP Code
Office Contact Name
Phone #
Prescriber Tax ID
Prescriber NPI Group NPIPrescriber State License #
Fax #
Email Address
First Name Last Name Practice Name
Prescription Information
Oral Shipment Information
3
4
Prescription/Schedule
Medication
Quantity
Rells
Directions
cabotegravir 30-mg tablet
rilpivirine 25-mg tablet
30 tablets
30 tablets
1 dosing kit
1 dosing kit
600-mg/900-mg kit: 600-mg single-dose vial of
cabotegravir + 900-mg single-dose vial of rilpivirine
400-mg/600-mg kit: 400-mg single-dose vial of
cabotegravir + 600-mg single-dose vial of rilpivirine
Continuation
Injections
Take 1 tablet by
mouth daily
Take 1 tablet by
mouth daily
Initiation Injections
None
None
None
PRN rells for 1 year
or
# of rells
2 injections
intramuscularly, monthly
2 injections
intramuscularly, once
Diagnosis Code:
ICD-10 Code
Prescriber Signature (Dispense as written)
Supervising/Collaborating MD Name (Please print, where required)
Prescriber Signature (Substitution permitted)
Collaborating Physician NPI (where required)
Prescriber Declaration (REQUIRED)
Date
I acknowledge the following: 1. I prescribed the ViiV medicine(s) indicated on this Enrollment Form for the Patient based on my judgment of medical necessity and will supervise the Patient’s
treatment. 2. I obtained the Patient’s authorization to release the information contained in this Enrollment Form and such other information as may be required by ViiV, its employees, agents,
or contractors to provide eligible ViiVConnect services for the Patient. 3. I authorize the forwarding of the prescription within this Enrollment Form to the dispensing specialty pharmacy on
behalf of myself and the Patient. 4. I understand that I may not seek reimbursement for any free product received under any program.
By signing below, I certify that the information I have provided in this Enrollment Form is complete and accurate to the best of my knowledge.
Ship oral medications to:
Patient’s Home Address
Prescriber’s Oce
Other (Please complete below)
State
ZIP Code
Street Address City
THE FOLLOWING INFORMATION SHOULD BE FILLED OUT BY YOUR HEALTHCARE PROVIDER
OR
Check box if none Check box if none
►
►
Request Spanish-language materials
cabotegravir / rilpivirine ENROLLMENT FORM
ViiVConnect provides comprehensive information on access and coverage
to help Patients get their prescribed ViiV Healthcare medications.
VIIVCONNECT.COM • PHONE: 1-844-588-3288 • FAX: 1-844-208-7676
This section of the form is intended as an optional way to prescribe. If your state restricts the use of this form to prescribe, or if this form does not meet your requirements
to prescribe, please attach a prescription to this form. Prescribers may need to submit an electronic prescription to the specialty pharmacy.
Please check all that apply:
Oral Lead-in
(Theracom distributed)
Form continued on the following page
2 o f 3
Injection Acquisition Information
6
My practice will acquire the injections through:
Buy & Bill
Specialty Pharmacy (Select one)*
Unknown/Undecided
Injections Will Be Administered at:
5
State ZIP CodeStreet Address
City
Phone #
Please check where the Patient’s injections will be administered:
NPI Tax ID
Facility Name Contact Name
At my oce
At the following (Please complete to the right)
Insurance Information (Please attach copies of front and back of all insurance cards)
7
Prescription Drug Plan Name
I have secondary insurance:
Policy ID #
Group
Yes No
Medical Insurance Name
Insurance Phone #
Policyholder:
Other (Please complete to the right)
Self
Policyholder (First Name, Last Name)
Relationship to Patient
BIN PCN
Insurance Phone #
Policy ID # Group
If applicable:
*Visit ViiVConnect.com or call 1-844-588-3288 for information on Patient eligibility for PAP.
†
If the Patient does not have a SSN, or they are unable to provide it, please note that income documentation may be required to review program eligibility.
1. What is the Patient’s ADAP status?
2
. Is the Patient enrolled in a Medicare plan, including Part B, Part D, or Advantage plans?
3
. Is the Patient eligible for any state or federal prescription drug coverage plan such as Medicaid or Puerto Rico’s Government
Healthcare Program, Mi Salud?
4
. Does the Patient have any private prescription drug coverage (including employer-sponsored plans, private group plans,
Marketplace plans/exchanges, etc.)?
•
If “yes,” please indicate why assistance is needed.
Yes
Yes
Yes
DeniedActive Not Applied/Not EligibleWait-listed Pending
No
No
No
•
If “yes,” eligibility requires documentation indicating the Patient paid at least $600 on prescription drugs in the current calendar year.
# of People Living in Household Who
Contribute to, or are Dependent
on, Patient’s Household Income
*Preferred Specialty Pharmacy selection will be honored if permitted by Patient’s insurance plan.
Social Security # (SSN)
†
US Resident?
Total Gross
Annual Income
Yes No
THE FOLLOWING INFORMATION SHOULD BE FILLED OUT BY YOUR HEALTHCARE PROVIDER
No preference
►
►
SECTION 8: PATIENT ASSISTANCE PROGRAM (PAP) —Complete only if applying for medication at no cost for eligible Patients*
►
cabotegravir / rilpivirine ENROLLMENT FORM
ViiVConnect provides comprehensive information on access and coverage
to help Patients get their prescribed ViiV Healthcare medications.
VIIVCONNECT.COM • PHONE: 1-844-588-3288 • FAX: 1-844-208-7676
Unknown
Accredo Health Group, Inc
AHF Pharmacy
Coordinated Care Network
Curant Health
CVS Specialty
Diplomat (Optum)
Fairview Specialty
Humana Specialty Pharmacy
Kroger Specialty Pharmacy
Opt u m/Avell a
AllianceRx Walgreens
Prime
Longs/Avita Specialty
Mail-Meds Clinical
Pharmacy
Meijer Specialty
I certify that the information provided within this Enrollment Form and Patient
Authorization and Release is true and correct. I understand that the collection,
use, and disclosure of certain information is protected under law. I understand
that Information contained in this Enrollment Form, such as my name, address,
insurance, prescription, and medical information, is “Protected Health Information.”
By signing below, I agree to the collection, use, and disclosure of my Protected
Health Information as described below. I understand that my healthcare providers
will not base any medical treatment decisions on my agreement to sign this Patient
Authorization and Release. I also understand that my agreement to sign this Patient
Authorization and Release and enroll in ViiVConnect is not required for my valid
prescription to be lled. I understand that once Protected Health Information is
collected, used, and/or disclosed based on this executed authorization, federal
privacy laws may not prevent the entities described below from further disclosing
my information. However, I understand that such entities have agreed to collect, use,
or disclose Protected Health Information received only for the purposes described
in this authorization or as required by law. I understand that ViiV Healthcare does
not charge a fee for participation in ViiVConnect programs. If my authorized Patient
Representative charges a fee for enrollment or rells of my free medicine received
under the Patient Assistance Program, this money is not paid by or paid to ViiV
Healthcare. I certify that any product that I receive from ViiV Healthcare is for my
own use and will not be sold, bartered, or given to any other person. I certify that the
information provided in this Enrollment Form is complete and accurate to the best
of my knowledge and agree to notify ViiVConnect of any change in my insurance
eligibility or nancial status. I understand that this authorization will remain in eect
for two (2) years, unless a shorter time period is mandated by state law. I also
understand that I have the right to revoke this authorization at any time by calling
1-844-588-3288 or mailing a signed, written statement of my revocation to
ViiVConnect, PO Box 220100, Charlotte, NC 28222-0100, but that such a revocation
would end my eligibility to participate in the programs as described. Upon receipt
and processing of written revocation of this authorization, further disclosures of
Protected Health Information will be prohibited. However, certain information
may still be collected, used, and disclosed for administrative purposes by ViiV
Healthcare and any other companies that ViiV Healthcare uses to collect, use, and
disclose such information.
Enrollment in ViiVConnect: The Patient and, if applicable, the Patient Representative
MUST sign this Patient Authorization and Release. Patient Representative must
dene their relationship to the Patient in the designated box below.
By signing this Patient Authorization and Release, I authorize ViiV Healthcare and
any other companies that ViiV Healthcare uses to collect, use, or disclose my
Protected Health Information to do the following:
VIIVCONNECT.COM • PHONE: 1-844-588-3288 • FAX: 1-844-208-7676
PATIENT AUTHORIZATION AND RELEASE
3 of 5
Form continued on the following page
If applicable, I authorize a Patient Representative to act on my
behalf pursuant to the Patient Representative Certication below.
I authorize ViiVConnect to provide me with information
on my benets and other communications that contain
reference to ViiVConnect through the following:
Yes
Yes
No
*
No
*
PhoneAny
Morning Afternoon Evening
EmailTex t Mail
A
B
C
PATIENT AUTHORIZATION AND RELEASE (SIGNATURE REQUIRED)
If I am unavailable when contacted, I authorize ViiVConnect
to leave a voicemail with the Access Coordinator’s name,
a reference to ViiVConnect, and a call back phone number.
I would prefer to be contacted by
phone at the following times:
Please sign below
4 of 5
Form continued on the following page
Patient Authorization and Release continued from previous page
1. Communicate with my doctor, healthcare providers (including pharmacies
and specialty pharmacies), and health insurer about my prescription, medical
condition, and treatment. I also authorize my doctor, healthcare providers
(including pharmacies and specialty pharmacies), and health insurer to
communicate with ViiV Healthcare about my prescription, medical condition,
and treatment.
2.
Request and receive from or send to my doctor, healthcare provider, health
insurer, or pharmacist information necessary to investigate and resolve my
insurance coverage, coding, or reimbursement inquiry, or review my eligibility
for Patient assistance programs and co-pay assistance.
3.
Collect, use, and disclose to each other any information that I provide to
ViiVConnect for investigating and resolving my insurance coverage, coding, or
reimbursement inquiry.
4. Disclose to my treating physician, healthcare provider, or pharmacist
information I provide to ViiVConnect when necessary to resolve my insurance
coverage, coding, or reimbursement inquiry. I also authorize my insurer, doctor,
healthcare provider, and pharmacist to release information about my prescribed
medications and medical condition requested by ViiVConnect.
5.
Contact my insurer, other potential funding sources, social workers, Patient
advocacy organizations, and/or Patient assistance programs on my behalf to
determine if I am eligible for health insurance coverage or other funds and
disclose to them information about my prescribed medications and medical
condition that has been provided to ViiVConnect by me or my physician,
healthcare provider, or pharmacist.
6.
Disclose any information obtained from the sources listed above to third parties
if required by law.
7.
Request additional documents and information at any time, even if I am already
enrolled so that ViiV Healthcare can determine if the information on this form is
complete and true.
†
Only complete this section if the Patient Representative enrolls the Patient and wants
to be the contact person and receive program correspondence on behalf of the Patient.
5 of 5
PATIENT REPRESENTATIVE CERTIFICATION
By my signature, I certify to the best of my knowledge that the information on this
Enrollment Form is correct and complete. I have no knowledge of any intent to sell, barter,
or give any free medicine received under the Patient Assistance Program to any person
other than the Patient for whom it has been prescribed. To the best of my knowledge,
the information about the Patient on this Enrollment Form is complete. I acknowledge
that the programs through ViiVConnect do not constitute health insurance. My signature
above also serves as attestation that the Patient has authorized me to act on their behalf.
As the Patient’s Representative, I authorize ViiV Healthcare and any other companies
that ViiV Healthcare uses to collect, use, and disclose the Patient’s information. I also
understand that I have the right to revoke this authorization on behalf of the Patient at any
time by calling 1-844-588-3288 or mailing a signed, written statement of my revocation
to ViiVConnect, PO Box 220100, Charlotte, NC 28222-0100, but that such a revocation
would end the Patient's eligibility to participate in the programs as described. Upon
receipt and processing of written revocation of this authorization, further disclosures of
Protected Health Information will be prohibited. However, certain information may still
be collected, used, and disclosed for administrative purposes by ViiV Healthcare or any
other companies that ViiV Healthcare uses to collect, use, or disclose such information.
Complete, sign, and electronically submit all pages of this form and applicable
corresponding documents (including the prescription) through the portal,
or fax to 1-844-208-7676 (toll-free).
For assistance, please call 1-844-588-3288 (toll-free),
Monday through Friday, 8 am to 11 pm ET.
Patient Name (Please print)
Name (Please print)
Patient Representative
†
Patient Signature
Signature ID # Phone #
Relationship
to Patient
Date
Date
*
If I do not authorize ViiVConnect to leave a voicemail with the Access Coordinator’s name,
a reference to ViiVConnect, and a call back phone number, I will be responsible for
contacting ViiVConnect.
Patient Authorization and Release continued from previous page
Trademarks are owned by or licensed to the ViiV Healthcare group of companies.
©2021 ViiV Healthcare or licensor.
ADR 2021.01 CABENUVA Enrollment Form (Digital) 1002 January 2021 Produced in USA.
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Form 1: cabotegravir rilpivirine ENROLLMENT FORM

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Completed 12 April 2021

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