Fill - Free fillable INSTRUCTIONS Complete all applicable sections of the Enrollment PDF form

INSTRUCTIONS

Complete all applicable sections of the Enrollment Form.

• Section 1 (required): Check the box next to each support oering you are requesting from Advancing Access®.

• Section 2 (required): Write the name and dosage of the Gilead product you are requesting assistance with from

Advancing Access.

• Section 3 (required): Complete all ﬁelds with the patient’s information.

• Section 4 (required): Check the appropriate box to indicate if the patient is insured or uninsured.

— If the patient is insured, ﬁll in the patient’s insurance information and fax a copy (front and back) of the patient’s

insurance card. If the patient has a secondary insurance, check the box to indicate this and fax a copy of the

secondary insurance card.

— If the patient is uninsured, complete Section 9 to apply to the Patient Assistance Program/Medication Assistance

Program (PAP/MAP).

• Section 5 (required): Complete all ﬁelds with the prescriber’s information.

• Section 6: A healthcare provider must provide the patient’s diagnosis and medical information.

• Section 7 (required): The prescriber must sign and date this section for reimbursement support and the Patient Assistance

Program/Medication Assistance Program (PAP/MAP).

• Section 8 (required): The patient (or the patient’s representative) must sign and date this section.

• Section 9 (required only if applying to the Patient Assistance Program/Medication Assistance Program (PAP/MAP)):

— Provide the patient’s annual household income and household size and complete the additional insurance

information portion.

— The patient must sign and date this section if applying to the PAP/MAP.

— Attach documentation for all sources of income.

Mail or fax the completed Enrollment Form and all required documentation to the Advancing Access program at the address

or fax number below. Both sets of information are necessary to ensure timely enrollment form review. You may complete an

electronic enrollment form online at https://advancingaccessconsent.iassist.com/.

An Advancing Access case specialist will notify the requestor about the patient’s coverage and beneﬁts, alternate funding

options and/or qualiﬁcation for the PAP/MAP, depending on the support requested.

PATIENT CONFIDENTIALITY

Patient conﬁdentiality is of primary importance to us. All patient information will remain conﬁdential. Information may be provided to

clinicians, social workers or family members when required to complete the enrollment process and coordinate patient assistance,

and to credit bureaus to determine program eligibility with your consent below.

IMPORTANT REMINDER

Please be certain that all applicable pages of the Enrollment Form are completed and include all appropriate documentation when

submitting the form. Incomplete forms slow the review process and, in some cases, may require a patient to reapply for the program.

Gilead Sciences, Inc. reserves the right to modify or discontinue the Advancing Access program or terminate assistance at

any time. Third-party reimbursement is aected by a range of factors; therefore, Gilead Sciences, Inc. cannot guarantee any

coverage or reimbursement.

CLEAR FORM

6. DIAGNOSIS/MEDICAL INFORMATION MUST BE COMPLETED BY HEALTHCARE PROVIDER

Diagnosis (Please include ICD code):_____________________________________________________

7. PRESCRIBER CERTIFICATION AND STATEMENT OF MEDICAL NECESSITY

By signing this form, I certify that I am prescribing Gilead medication for the patient identiﬁed in Section 3. I certify that this prescription medication is medically necessary for the

patient and that it will be used as directed. I certify that I will be supervising the patient’s treatments and verify that the information provided is complete and accurate to the best

of my knowledge. I agree that I shall not seek reimbursement for any Gilead medication dispensed to the patient through the Patient Assistance Program/Medication Assistance

Program (“PAP/MAP”) from any government program or third-party insurer.

If prescribing DESCOVY

or TRUVADA for PrEP™, I certify that the applicant has been tested for HIV infection and found to be HIV negative, and regular HIV testing will be conducted

as part of the applicant’s care plan. As part of my applicant’s eligibility, I agree to periodically verify continued use of Gilead medication and resubmit current prescriptions.

I certify that I have received the appropriate written authorization from the patient, in accordance with the Health Insurance Portability and Accountability Act of 1996, applicable state

health information privacy law(s), and any other applicable requirements, in order to release the patient’s personal and medical information to Gilead and its agents and contractors for

the purposes of: 1) verifying the patient’s insurance coverage and eligibility for beneﬁts; 2) seeking prior authorization if needed on the patient’s behalf; 3) providing ﬁnancial assistance,

support, and referral support as needed; 4) facilitating the provision of the patient’s prescription medication to the patient; 5) contacting the patient with educational materials about the

patient’s prescription medication or to evaluate the eectiveness of the Advancing Access Program and/or the PAP/MAP; and 6) for Gilead’s internal business purposes.

PRESCRIBER SIGNATURE (REQUIRED): DATE: / /

ENROLLMENT FORM PAGE 1 OF 3

PHONE: 1-800-226-2056 FAX: 1-800-216-6857

5. PRESCRIBER INFORMATION REQUIRED

Prescriber Name: Facility Name:

Address: City:

State: Zip Code: Oce Contact:

Phone #: ( ) – Fax #: ( ) – NPI #:

Tax ID #: State License #:

4. INSURANCE INFORMATION REQUIRED PLEASE INCLUDE A COPY OF THE FRONT AND BACK OF INSURANCE CARDS

Patient is insured

(Please ﬁll out all of the applicable insurance information

below. Attach copy—front and back—of patient card.)

Patient is uninsured (ie, no health insurance through any public or private payer)

SEE OPTIONAL “PATIENT FINANCIAL INFORMATION” SECTION 9 BELOW

Primary Insurance: Is this a Medicare Part D plan? Yes No

Plan name: Insurance Phone Number:

Subscriber

Name:

Policy Holder

Name:

Policy Holder

Relationship to Patient:

Policy #: Group #: Rx Bin #: Rx PCN #:

Check box if patient has secondary insurance coverage and fax a copy of insurance cards, if available.

3. PATIENT INFORMATION REQUIRED

First Name: Last Name: M.I.: Preferred L

anguage:

Address: Apt./Unit # City:

State: Zip Code: Phone #: ( ) – SSN# (Last 4 digits):

Email: DOB: / /

Alternate Contact Name: Phone #: ( ) – Relationship:

CONTACT AUTHORIZATION

I authorize Advancing Access to leave a detailed message, including the name of my prescription, if I am unavailable when they call.

I authorize Advancing Access to send me correspondence via U.S. mail. This includes, but is not limited to approval/denial letters for the Patient

Assistance Program, reminder letters for re-enrollment periods, etc. If I select “No”, I understand that all communication will be via phone.

Yes No

2. GILEAD MEDICATION PRESCRIBED REQUIRED

Product Name: mg:

If requesting DESCOVY

or TRUVADA

, please indicate for:

Treatment PrEP/Prevention

1. REQUESTED PATIENT SUPPORT REQUIRED CHECK ALL BOXES THAT APPLY

Beneﬁts Investigation Prior Authorization and Appeals Information Co-pay Coupon Program Enrollment

Patient Assistance Program (PAP) or Medication Assistance Program (MAP) Eligibility Screening

CLEAR FORM

By checking this box, I agree to receive marketing information, oers and educational materials related to my medical condition, treatment, and/or my

prescription medication, including the customer relationship marketing program.

SIGNATURE of PATIENT or PATIENT’S REPRESENTATIVE (REQUIRED): DATE:

Patient Representative’s Name (if signing for the patient):

Patient Representative’s Relationship to Patient:

FAX COMPLETED FORM TO ADVANCING ACCESS AT 1-800-216-6857

8. PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION REQUIRED

I understand that I must complete this enrollment form before I can receive assistance through Gilead Sciences, Inc.’s

Advancing Access (“Program”) and the Patient Assistance Program/Medication Assistance Program (“PAP/MAP”). As part

of this process, Gilead and its agents and contractors (collectively, “Gilead”) will need to obtain, review, use and disclose

my personal and medical information as described below. I hereby authorize my healthcare providers and health plans to

disclose my personal and medical information as described below to Gilead in connection with the Program and/or the

PAP/MAP, all in accordance with this authorization, and I authorize Gilead to use and disclose the information in accordance

with the authorization.

Information to Be Disclosed: Personal health information (“PHI”), including information about me (for example, my

name, mailing address, nancial information, and insurance information), my past, current and future medical condition

(including information about my HIV-related status or treatment with this prescription medication and related medical

condition), and all information provided on this enrollment form.

Persons Authorized to Disclose My Information: My healthcare providers, including any pharmacy that lls my prescription

medication, and any health plans or programs that provide me healthcare benets. I understand that my pharmacy

providers may receive remuneration for disclosing my PHI pursuant to this authorization.

Persons to Which My Information May Be Disclosed: Gilead, including the third party administrator responsible for the

administration of the Program and the PAP/MAP.

Purposes for Which the Disclosures Are to Be Made: Disclosures of PHI may be made to Gilead so that Gilead may use and

disclose the PHI for purposes of: 1) completing the enrollment process and verifying my enrollment form; 2) establishing

my eligibility for benets from my health plan or other programs; 3) providing nancial assistance, support, and referral

support, and communicating with my healthcare providers, including, but not limited to, facilitating the provision of my

prescription medication to me; 4) contacting me to evaluate the effectiveness of the Program and/or the PAP/MAP; 5) for

Gilead’s internal business purposes, including quality control and support enhancing surveys; and 6) to send me marketing

information, offers, and educational materials related to my treatment and/or my prescription medication, including the

customer relationship marketing program (this use of my personal information is optional and by checking the box under

the signatures below, I may opt in).

I understand that once my PHI has been disclosed hereunder, federal privacy law may no longer restrict its use or disclosure.

I understand further that I may refuse to sign this authorization and that if I refuse, my eligibility for health plan benets or

ability to obtain treatment from my healthcare providers will not change, but I will not have access to the support offered

by Program and/or the PAP/MAP. I also understand that I may cancel this authorization at any time by notifying Gilead in

writing at Advancing Access, PO Box 13185, La Jolla, CA 92039-3185. If I cancel, Gilead will stop using this authorization

to obtain, use or disclose my PHI after the cancellation date, but the cancellation will not affect uses or disclosures of any

PHI that have already been made pursuant to this authorization before the cancellation date. I am entitled to a copy of this

signed authorization, which expires the earlier of two (2) years from the date it is signed by me or other time period required

under the laws of the state in which I reside.

ADVANCING ACCESS ENROLLMENT FORM PHONE: 18002262056 FAX: 18002166857 PAGE 2 OF 3

PATIENT NAME: __________________________________________________________________ DATE OF BIRTH: __________________________ ___________________________

/ /

9. PATIENT FINANCIAL INFORMATION REQUIRED ONLY IF APPLYING FOR THE PATIENT ASSISTANCE PROGRAM/MEDICATION ASSISTANCE PROGRAM PAP/MAP

Current Annual Household Income: $

Number of People in Household supported by above income

1 2 3 4 5 6 Other:

ADDITIONAL INSURANCE INFORMATION

Social Security Number:

Has the patient applied for ADAP or PrEP DAP? If Yes, date of application:

Has the patient applied for Medicaid? If Y

es, date of application:

Is the patient eligible for Medicaid? If No, state reason:

Is the patient eligible for VA beneﬁts?

If Yes, has the patient tried to obtain

the medication through the VA?

Has the patient applied for an insurance plan oered through

a state insurance marketplace (also known as an exchange)?

If Yes, date of application:

Is the patient eligible for an insurance plan oered through

a state insurance marketplace (also known as an exchange)?

If No, state reason:

Yes No

APPLICANT DECLARATIONS AND AUTHORIZATIONS REQUIRED ONLY IF APPLYING FOR THE PAP/MAP

I certify that all of the information provided in this application, including household income, is complete and accurate. I understand that program assistance

will terminate if Advancing Access becomes aware of any false or inaccurate information or if this medication is no longer prescribed for me. I understand that

completing this application does not ensure that I will qualify for patient assistance. If I receive free product through the PAP/MAP, I certify that I will not seek

reimbursement or credit for this medication from any insurer, health plan, or government program. If I am a member of a Medicare Part D plan, I will not seek

to have this medication or any cost for items associated with it counted as part of my out-of-pocket cost for prescription drugs. I understand that the PAP/

MAP reserves the right to modify the application form, modify or discontinue this program, or terminate assistance at any time and without notice. I authorize

the PAP/MAP and its administrator to forward my prescription to a dispensing pharmacy on my behalf. Advancing Access may require you to submit proof of

income documentation to verify your eligibility into the patient assistance/medication assistance program (eg, tax return, W2, last 2 pay stubs, etc.). I authorize

Gilead and its third party administrator to use the information provided on this form to obtain a personal credit report about me to verify the information

on this form and determine my eligibility for the PAP/MAP.

SIGNATURE OF PATIENT/PATIENT REPRESENTATIVE:

(REQUIRED ONLY IF APPLYING FOR PAP/MAP)

DATE:

FAX COMPLETED FORM TO ADVANCING ACCESS AT 1-800-216-6857

ADVANCING ACCESS ENROLLMENT FORM PHONE: 18002262056 FAX: 18002166857 PAGE 3 OF 3

PATIENT NAME: __________________________________________________________________ DATE OF BIRTH: __________________________ __________________________

ADVANCING ACCESS, GILEAD, the GILEAD logo, DESCOVY, TRUVADA and TRUVADA for PrEP are trademarks of Gilead Sciences, Inc., or its related companies.

/ /

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