Fillable GSK Patient Assistance Program The GSK Patient Assistance (East Carolina University)

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GSK Patient Assistance Program The GSK Patient Assistance (East Carolina University)

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GSK Patient Assistance Program
PO Box 220590, Charlotte, NC 28222-0590
Phone: 1-866-728-4368, Fax: 1-855-474-3063
Monday – Friday 8am-8pm ET
APP-000001 Page 1 of 5
GSK Patient Assistance
Program
Application Check List:
Call 1-866-728-4368 with any questions about how to complete this form
The GSK Patient Assistance Program provides certain GSK medicines at no cost to eligible applicants. Eligibility is
based on household income and insurance status. Residents of the United States and District of Columbia may be
eligible for both Vaccine and Non-Vaccine Medicines. Residents of Puerto Rico may be eligible for Non-Vaccine
Medicines only. Please be aware, this program does not constitute health insurance
.
Complete the entire form. An incomplete application will delay processing.
Fax or mail the following:
Completed and signed application.
Signed prescription. Signed original prescription(s) for GSK medication(s) written as medically appropriate.
Note: Faxed prescriptions will only be accepted as valid if faxed directly from a physician’s office and
accompanied by a fax cover sheet.
Non-Vaccine Applications Only:
● Medicare Part D applicants must also send:
● Proof that they have spent $600 out-of-pocket on prescription medications.
Documentation includes all pages of the patient’s most recent Medicare Part D prescription drug plan
statement (Explanation of Benefits – EOB) indicating the patient has paid a total of $600 for
prescriptions in the current calendar year. If the statement is not available, please call the GSK PAP at
1-866-728-4368 for help to identify other sources of proof.
Note: The $600 expenditure can be co-pays, deductibles and direct costs for any prescription
medication. The prescription expenses must not include monthly premiums or expenses of family
members.
● A copy of their Medicare Part D prescription drug card. Please do not send original card(s).
● Medicare Part D patients are not eligible for Vaccine Medicines.
● Advocate information required if enrolling by phone.
Vaccine Applications Only:
● Prescriber shipping information and certification.
Please keep a copy of the application and all documents for your record. Do not send original documents
as they will not be returned.
GSK Patient Assistance Program
PO Box 220590, Charlotte, NC 28222-0590
Phone: 1-866-728-4368, Fax: 1-855-474-3063
Monday – Friday 8am-8pm ET
APP-000001 Page 2 of 5
Patient Name: _________________________________ Patient ID: ___________________ DOB: __________________
Section 1: Applicant Information Required
Name (First):____________________________ (Last): ____________________________ (M.I.): ______ Gender:
M F
Mailing Address: _________________________________________ City: ___________________ State: _____ Zip: ____________
Primary Phone Number: (____) _____-_______ Birth Date: _____/_____/________ Social Security #
1
:_____-_____-______
MM DD YYYY
If you would like to receive GSK patient assistance alerts, notifications and updates through email, please provide an email address.
Email: ______________________________________________________________________________________________________
Number of people, including applicant, who live in the household? _____ Number of people dependent on household income? ______
Total Gross Monthly Income: _________________________________ or Gross Annual Income: ____________________________
GSK Medication(s) Requested Required: ________________________________________________________________________
Drug Allergies Required: Do you have any known drug allergies? Yes
No
If Yes, list any known drug allergies: ______________________________________________________________________________
___________________________________________________________________________________________________________
Health Conditions Required: Do you have any known health conditions? Yes
No
If Yes, list any known health conditions: ____________________________________________________________________________
___________________________________________________________________________________________________________
Section 2: Prescription Coverage Required
1. Does the applicant have prescription drug coverage through a Health Insurance Marketplace
Plan/Exchange (also known as Affordable Care Act)? Yes
No
2. Is the applicant eligible for any state or federal (not including Medicare Part D) prescription drug
coverage plan such as Medicaid? Yes
No
3. Does the applicant have any private prescription drug coverage (including employer sponsored
plans, private group plans, etc.)? Yes
No
● If yes to question 3, please indicate why assistance is needed: __________________________________________________
Non-Vaccine Applications Only:
4. Is the applicant enrolled in a Medicare Part D prescription drug plan? Yes
No
● If not, check no and skip to question number 5.
● If yes, has the applicant spent $600 or more on prescription expenses since January 1
st
of the current calendar year?
If yes, please provide the patient’s most recent Medicare Part D prescription drug plan statement (EOB) indicating the patient
paid a total of $600 for prescriptions in the current calendar year.
If no, please wait until the applicant has spent $600 or more to apply.
5. Is the applicant eligible for Puerto Rico’s Government Healthcare Program, Mi Salud? Yes
No
1
The sole purpose of the Social Security Number is to determine income eligibility without the need to provide documentation. If you do not
have a Social Security Number or you are unable to provide it please note that income documentation may be required to determine your
eligibility for the program.
GSK Patient Assistance Program
PO Box 220590, Charlotte, NC 28222-0590
Phone: 1-866-728-4368, Fax: 1-855-474-3063
Monday – Friday 8am-8pm ET
APP-000001 Page 3 of 5
Patient Name: _________________________________ Patient ID: ___________________ DOB: __________________
Section 3: Shipping Address Required
Vaccines Only, Required Replenishment Prescriber Shipping Address
Prescriber Registration ID #:______________________________________
Prescriber must register for the Vaccines patient assistance program only. Enroll online at GSKPatientAssistanceProgramPortal.com. If
there are any questions regarding the registration process, please call 1-866-728-4368.
Prescriber Name: ___________________________________ SLN #: ___________________ Expiration Date: ______________
Prescriber Email address: _______________________________________________________________________________________
Clinic Name: _________________________________________________________________________________________________
Street Address: ___________________________________________ City: ___________________ State: ______ Zip: ____________
Phone Number: (____) _____-_______ Fax Number: (____) _____-_______
Preferred Delivery Day:
Tuesday
Wednesday
Thursday
Friday
Non-Vaccines Only, Required If Different From Mailing Address
Addressee or Business Name: ___________________________________________________________________________________
Street Address: ___________________________________________ City: ___________________ State: ______ Zip: ____________
Phone Number: (____) _____-_______ Fax Number: (____) _____-_______
Specify addressee’s relationship to the applicant:
Self
Advocate (must complete Advocate Information in Section 5)
Prescriber
Other (specify relationship) _____________________________
Refills Are Not Automatically Shipped. Please Visit Us Online Or Call Us To Request Your Refill.
Section 4: Authorized Individuals
For the patient: If you would like to give permission to GSK for other individuals (i.e. adult child, parent, friend) to conduct business on
your behalf, please print their names here. Please note: These individuals are in addition to a legal guardian or registered advocate who
may already be included on this application.
First Name: _______________________ Last Name: _______________________ Relationship to Patient: ____________________
First Name: _______________________ Last Name: _______________________ Relationship to Patient: ____________________
First Name: _______________________ Last Name: _______________________ Relationship to Patient: ____________________
First Name: _______________________ Last Name: _______________________ Relationship to Patient: ____________________
If you (the patient) or any of the above listed authorized individuals would like to receive GSK patient assistance alerts, notifications and
updates through email, please provide an email address below.
Email Address: _______________________________________________________________________________________________
GSK Patient Assistance Program
PO Box 220590, Charlotte, NC 28222-0590
Phone: 1-866-728-4368, Fax: 1-855-474-3063
Monday – Friday 8am-8pm ET
APP-000001 Page 4 of 5
Patient Name: _________________________________ Patient ID: ___________________ DOB: __________________
Section 5: Non-Vaccines Only, Advocate Information
Advocate ID #:______________________________________ Email Address: ____________________________________________
Register at www.GSKPatientAssistancePortal.com or by calling 1-866-728-4368
Facility Name: __________________________ First Name: ___________________ Last Name:___________________ M.I.: _______
Street Address: ___________________________________________ City: ___________________ State: ______ Zip: ____________
Primary Phone Number: (____) _____-_______ Fax Number: (____) _____-_______
By my signature, I certify to the best of my knowledge, the information on this application is correct and complete. I have no knowledge of, nor do
I have any intent to, sell, barter or give this product to any person other than the Applicant for whom it has been prescribed. I have no knowledge,
the Applicant has no medical/prescription insurance benefits for the indicated pharmaceutical(s), including Medicaid or other public programs
other than as indicated, and the Applicant has insufficient financial resources to pay for the prescribed therapy.
Advocate Signature: ______________________________________________________ Date: ____________________
(Original signature required. Stamped signature not accepted)
If you would like to receive GSK patient assistance alerts, notifications and updates through email, please provide an email address.
Email: ______________________________________________________________________________________________________
Section 6: Vaccines Only Required Prescriber Information and Certification
My signature certifies that I am a licensed practitioner eligible under state law to prescribe, receive, and administer the requested
medication(s) listed on this program enrollment form, shipped from GSK Patient Assistance Program (GSK PAP). I attest that the vaccine
requested is indicated medically for the identified patient. I certify to the best of my knowledge, that the information on this application is
correct and complete. I attest that the product I receive is a replacement of a previously purchased GSK vaccine. I also understand that
eligibility under the program is subject to GSK’s discretion and GSK reserves the right to modify or terminate the GSK PAP at any time. I
represent that I have obtained all necessary authorizations from my patient to allow me to release information to GSK and its contracted
third parties.
My signature confirms that the vaccine product will be provided at no cost to the patient listed on this form and I understand that I am not
eligible to seek reimbursement from any source for any medication provided by the GSK PAP. I understand that I will not receive
reimbursement from GSK for the administration of this vaccine and further agree that I will not seek reimbursement for administration of
the vaccine from any public payer.
Prescriber Signature: ______________________________________ Date: _______________________________________
(
Original signature required. Stamped signature not accepted.)
GSK Patient Assistance Program
PO Box 220590, Charlotte, NC 28222-0590
Phone: 1-866-728-4368, Fax: 1-855-474-3063
Monday – Friday 8am-8pm ET
APP-000001 Page 5 of 5
Patient Name: _________________________________ Patient ID: ___________________ DOB: __________________
Section 7: Patient Certification Required
By my signature I authorize GSK, as well as Lash Group and any other companies that GSK uses to administer the GSK Patient Assistance
Program (GSK PAP) (the “Program”) to do the following:
1) Use any information that I provide in my application for the purpose of helping me receive GSK products under the program or to administer
the Program.
2) Receive and keep records of all prescriptions for the medications I receive under the Program, which will be used to administer the Program;
3) Contact my doctor, healthcare provider, or pharmacist about my application for the Program, and disclose to them information contained in
my application, in order to help me receive GSK products under the Program and ensure that program guidelines are being met;
4) Request information from my insurer, doctor, healthcare provider, or pharmacist about the prescribed medications I receive or will receive
under the Program and about my medical condition. This information will be used only to determine my eligibility for the Program and to
administer the Program;
5) Contact my insurer, other potential funding sources, including the Centers for Medicare and Medicaid Services, social workers or patient
advocacy organizations on my behalf in order to determine if I am eligible for health insurance coverage or other funds, and disclose to them
information contained in my application or information about my prescribed medications and medical condition that has been provided by my
physician, healthcare provider, or pharmacist;
6) Disclose any information obtained from the sources listed above to third parties if required by law.
7) Authorize GSK PAP and its Administrators to obtain a consumer report on me. My consumer report, and the 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 medication from GSK
PAP. Upon request, GSK PAP will provide me the name and address of the consumer reporting agency that provides the consumer report.
8) Request additional documents and information at any time, even if I am already enrolled, so that they can decide if the information on this
form is complete and true.
I understand that GSK does not charge a fee for participation in the Programs. If I have used a third party who charges a fee for help with my
enrollment form or refills of my medicine, this money is not paid to GSK. I understand this Authorization to Release and Disclose Medical
Information will remain in effect for as long as I participate in the Programs and for a period of 7 years after my participation in the Program ends. I
understand my healthcare providers will not condition my medication treatment on my agreement to sign this Authorization to Release and
Disclose Medical Information. I also understand that I have the right to revoke this authorization at any time by calling 1-866-728-4368, and
mailing a signed written statement of my revocation to the Program. Such a revocation would end my eligibility to participate in the Program.
Revoking this authorization will prohibit disclosures after the date written revocation is received, except to the extent that action has been taken in
reliance on my authorization. I understand that once medical information about me has been disclosed in reliance upon this Authorization, the
information may no longer be protected by federal privacy laws and may be further disclosed. I certify that the product I receive from GSK PAP 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 application is complete and
accurate to the best of my knowledge and agree to notify GSK of any change in my insurance eligibility or financial status.
Patient or Legal Guardian Signature: __________________________________________ Date: _____________________
(Original signature required.)
Relationship (if other than Applicant): _________________________________________________________________________
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GSK Patient Assistance Program The GSK Patient Assistance (East Carolina University)

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Completed 3 February 2022

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