PATIENT APPLICATION FORM INSTRUCTIONS

Transcription

1 INSTRUCTIONS The Safety Net Foundation is a nonprofit patient assistance program that helps qualifying uninsured patients access Amgen medicines at no cost. To apply online, access program information or download additional forms visit us at TO APPLY FOR THE FOUNDATION FOR REPLACEMENT PRODUCTS The product replacement program applies to products that are administered by a provider in an outpatient setting. To enroll in these products, the patient s healthcare provider must first complete a Facility Application Form and be enrolled as a Safety Net Foundation facility (only required once per facility). Once enrolled, the provider will then complete and submit the Patient Application Form, along with the patient's signature and supporting income documentation, on behalf of the patient. Products included in the replacement program are: Aranesp (darbepoetin alfa) EPOGEN (Epoetin alfa) (for dialysis use only) Neulasta (pegfilgrastim) NEUPOGEN (Filgrastim) Nplate (romiplostim) Prolia (denosumab) injection Vectibix (panitumumab) injection XGEVA (denosumab) On behalf of the patient, read and complete the Patient Application Form. Failure to provide required information will delay the enrollment decision. Obtain the patient s signature at the bottom of page 5. Obtain the patient s latest federal or state tax return latest W-2 statement SSDI/SSI award letter proof of household income. At least one of the following must be submitted: bank statements (last 3 months showing income deposits) pay stubs (last 2 pay stubs) state program acceptance letter or card Fax the completed Patient Application Form and proof of household income to TO APPLY FOR THE FOUNDATION FOR PROSPECTIVE PRODUCTS The prospective product program applies to product shipped directly to the provider or to the patient prior to product administration. Patients should enroll directly with the Foundation. The Product Prescription Form must be submitted along with this Patient Application as part of the patient enrollment process. Products included in the prospective program are: Prolia (denosumab) injection (bone health patients only) Sensipar (cinacalcet) Read and complete the Patient Application Form. Failure to provide required information will delay the enrollment decision. Have your treating physician complete the Product Prescription Form. Patient s signature is required at the bottom of page 5. Patient s proof of household income is required. You must submit at least one of the following: latest federal or state tax return bank statements (last 3 months showing income deposits) latest W-2 statement pay stubs (last 2 pay stubs) SSDI/SSI award letter state program acceptance letter or card Fax the completed Patient Application Form, proof of household income and the Product Prescription Form to If you are mailing application send to: The Safety Net Foundation PO BOX 13185, La Jolla, CA Rev: 10/7/11 Page 1 of 5

2 For assistance in completing this application, please call SN-AMGEN ( ). Submission of this form is required to begin enrollment of a patient in The Safety Net Foundation sponsored by Amgen. Information supplied on this form will be strictly confidential. Patient Information: Patient s First Name: Patient s Last Name: Date of Birth: Sex: (MMDDYYYY) Address: City: State: Zip: Primary Phone #: Primary Phone # Type: Home Work Mobile Secondary Phone #: Secondary Phone # Type: Home Work Mobile Fax #: Does the patient live in the United States? Yes No Patient s Address: Patient s Preferred Method for Written Communications: Fax Mail Annual Household Income $ (Proof of income is required. See Patient Application Form Instructions for a list of acceptable documents.) Source of Income: # of Persons in Household: Insurance Information (Please complete the information below to describe your health insurance status) Does the patient have health insurance? Yes No (If yes, the section below is required) Insurance Coverage (Ex: Blue Shield of CA, AARP, VA/DOD, Indian Health Service, Discount Card Program) Primary Patient Insurance Policy Payor Name: Plan Name: Policy #: Policy Phone #: Subscriber Relation to Patient: Subscriber First Name: Subscriber Last Name: Subscriber Employer: Group #: Secondary Patient Insurance Policy Payor Name: Plan Name: Policy #: Policy Phone #: Subscriber Relation to Patient: Subscriber First Name: Subscriber Last Name: Subscriber Employer: Group #: Medicare (A, B) Yes Denied Pending N/A Effective Date: ) Medicare Part D (Prescription Drug Plan) Yes Denied Pending N/A Effective Date: Medicaid ) Yes Denied Pending Emergency N/A Effective Date: ) Rev: 10/7/11 Page 2 of 5

3 Patient s First Name: Patient s Last Name: Facility Mailing Information (Facility information is not required for Sensipar (cinacalcet) or Prolia (denosumab) injection for bone health patients going through the prospective shipment model. Go to Physician Information section for these products.) Facility Name: Contact Person Name: Address: City: State: Zip: Phone #: Fax #: Facility Product Shipping Information Check if shipping is same as mailing information Confirm address where product should be shipped (if different from above.) Facility Name: Contact Person Name: Address: (PO BOX is not accepted) City: State: Zip: Phone #: Physician Information: Physician s First Name: Physician s Last Name: Physician s Facility Name: Phone #: Fax #: Rev: 10/7/11 Page 3 of 5

4 Patient s First Name: Patient s Last Name: Product Information Products Utilized by Patient*: Aranesp (darbepoetin alfa) Prolia (denosumab) injection EPOGEN (Epoetin alfa) (for dialysis use only) Neulasta (pegfilgrastim) NEUPOGEN (Filgrastim) Sensipar (cinacalcet) Vectibix (panitumumab) injection XGEVA (denosumab) Nplate (romiplostim) Please Note: *To obtain replacement product for Aranesp, EPOGEN, Neulasta, NEUPOGEN, Vectibix, and Nplate, Prolia, and XGEVA, please submit a Facility Application Form if your facility is not currently enrolled in The Safety Net Foundation. *To obtain prospective product for Prolia (bone health patients only) and Sensipar, the Product Prescription Form must be submitted along with this Patient Application as part of the patient enrollment process. For Aranesp (darbepoetin alfa) which therapeutic area is the patient being treated for? Nephrology Oncology For EPOGEN (Epoetin Alfa) patients: Is the patient currently on dialysis? Yes No First date of dialysis: Estimated EPOGEN dose/week: For Nplate (romiplostim) patients: Nplate Patient Diagnosis: Nplate NEXUS Patient ID#: Nplate NEXUS Physician ID#: For Prolia (denosumab) which therapeutic area is the patient being treated for? Bone Health Oncology For Prolia (denosumab) injection bone health patients, what is your preferred treatment fulfillment model? Obtain this information from the facility contact or treating physician. Replacement Prospective For Internal Use Only Facility Customer Number: Rev: 10/7/11 Page 4 of 5

5 Patient s First Name: Patient s Last Name: PATIENT CERTIFICATION AND AUTHORIZATION TO DISCLOSE INFORMATION The Safety Net Foundation ( the Foundation ) is a nonprofit patient assistance program supported by Amgen that provides qualifying patients with Amgen products at no cost. I authorize the Foundation, Amgen, and their agents authorized to administer the Foundation to: use the information that I provided on the Foundation application form to determine my eligibility for and assist with my continued participation in the Foundation. use my social security number to access my credit information and information derived from other public sources to estimate my income in conjunction with the eligibility determination process. For these purposes, I also authorize the sharing of information about my medical condition, treatment, and health insurance coverage between my physician, healthcare professionals, care givers, and family members and the Foundation, Amgen, and their agents authorized to administer the Foundation. I certify that: the information I provided on the Foundation application form is complete and accurate. I will not request reimbursement from any insurance carrier or government health benefit program for any Amgen products I receive from the Foundation. I will notify the Foundation within thirty (30) days if my financial status or health insurance coverage changes. I will not sell, trade, or distribute Amgen products given to me by the Foundation. I understand that: completing the Foundation application form is not a guarantee of eligibility for the Foundation. the Foundation may change or discontinue the program at any time without notice. I may refuse to sign this form, but if I refuse to sign or revoke my authorization, I will not be able to receive assistance from the Foundation. my healthcare provider or insurers will not condition my medical treatment or insurance benefits on my agreement to sign this form. once I provide the information on the Foundation application form to the Foundation, Amgen and the agents working on their behalf pursuant to this authorization, federal privacy laws may not prevent further disclosure of this information. I may receive a copy of this form or revoke it at any time by contacting the Foundation at SN- AMGEN ( ). this authorization will expire one (1) year after the date it is signed below or one (1) year after the last date I receive product from the Foundation, whichever is later. Signature of patient or legal representative Date Print name of patient or legal representative Rev: 10/7/11 Page 5 of 5