The Safety Net Foundation

Transcription

1 The Safety Net Fundatin Instructins fr Kineret (anakinra) and Sensipar (cinacalcet HCl) Instructins The Safety Net Fundatin prvides temprary prduct assistance t financially needy patients wh meet predetermined eligibility criteria. T receive free prduct, the prescriber and patient must cmplete a Safety Net Fundatin applicatin. T btain an applicatin r t initiate the applicatin prcess, please call The Safety Net Fundatin at SN- AMGEN ( ). Cunselrs are available Mnday thrugh Friday, 9:00 a.m. t 8:00 p.m., Eastern Time. T apply fr the Fundatin patients and their physicians shuld cmplete the fllwing: 1. Patient Prtin The patient must cmplete Frm B: Patient Frm in its entirety. The Frm B includes required demgraphic, insurance, and financial infrmatin. The patient is required t sign the Applicatin Declaratin. Prvide prf f incme. The patient may submit any ne f the fllwing: latest federal r state tax return, latest W-2 statement, SSDI/SSI award letter, bank statements (last 3 mnths shwing incme depsits), pay stubs (last 2 pay stubs), r state prgram acceptance letter r card (e.g. ORSA). If the patient des nt have prf f incme, yu may cmplete ne f the fllwing frms: ntarized incme statement (frm enclsed), r attestatin statement with tw signatures (frm enclsed). By signing this frm, the patient prvides authrizatin fr their prvider t disclse the infrmatin requested in Frm A f the applicatin. Frm B shuld be cmpleted by the patient and a cpy shuld be given t the prvider fr their recrds. 2. Physician Prtin The patient s physician must cmplete Frm A: Physician Prtin in its entirety. General prvider and prescriptin infrmatin is required. In additin, the physician s state license number (SLN) is required n Frm A. The prvider is required t sign the Physician Declaratin. Page 1 f 7

2 Instructins fr Kineret (anakinra) and Sensipar (cinacalcet HCl) cntinued Mail r physician ffice staff may fax the cmpleted applicatin (Patient Frm [Frm B], Physician Frm [Frm A], and prper incme dcumentatin) t: The Safety Net Fundatin PO Bx La Jlla, CA Tel: SN-AMGEN ( ) Fax: Faxed cpies f applicatins are accepted, but must be sent frm the physician s ffice. Once we receive a cmplete applicatin, bth patient and physician will be ntified f patient s eligibility. Fr any questins please call , Mnday thrugh Friday, 9am t 8pm Eastern Time. Sincerely, The Safety Net Fundatin The Safety Net Fundatin reserves the right t mdify r discntinue this prgram with respect t any patient, r in its entirety, at any time. The Safety Net Fundatin als reserves the right t make an independent determinatin f financial and medical need. Page 2 f 7

3 NOTARIZED INCOME STATEMENT Only use this frm if yu cannt prvide prf f incme dcumentatin. Name: SS#: Date f Birth: My estimated annual husehld incme currently is $. (Please include dllar amunt) $ Scial Security Disability Incme (SSDI) (Beginning / ) $ Supplemental Security Incme (SSI) $ Aid frm the Department f Public Welfare $ Unemplyment Benefits (Frm / t / ) $ Wrkers Cmpensatin Benefits (Frm / t / ): $ Dividends, interest, r investment accunts $ Emplyment (Myself and/r my spuse) $ Other (includes assistance frm family, friends, charity, r church. Please specify the amunt f financial assistance yu receive - may include percentage f rent, fd, etc.) Number f Peple in Husehld: YOU MUST HAVE THIS FORM NOTARIZED IN ORDER TO PREVENT A DELAY IN THE PROCESSING OF YOUR APPLICATION. Patient Signature Ntary Seal Date Ntary Signature Ntary Date Page 3 f 7

4 Frm B: PATIENT FORM ATTESTATION FORM Only use this frm if yu cannt prvide prf f incme dcumentatin. Name: SS#: Date f Birth: My estimated annual husehld incme currently is $. (Please include dllar amunt) $ Scial Security Disability Incme (SSDI) (Beginning / ) $ Supplemental Security Incme (SSI) $ Aid frm the Department f Public Welfare $ Unemplyment Benefits (Frm / t / ) $ Wrkers Cmpensatin Benefits (Frm / t / ): $ Dividends, interest, r investment accunts $ Emplyment (Myself and/r my spuse) $ Other (includes assistance frm family, friends, charity, r church. Please specify the amunt f financial assistance yu receive - may include percentage f rent, fd, etc.) Number f Peple in Husehld: Spnsr Cntact Attestatin: Spnsr cntact may sign belw t attest t the patient s financial situatin. T the best f my knwledge, I knw the financial infrmatin prvided n this applicatin t be true. Print Name: Title: Original Signature: (Stamps nt accepted) Date: Patient Signature: Date: Page 4 f 7

5 Frm B: PATIENT FORM The Safety Net Fundatin Applicatin Fr Kineret (anakinra) and Sensipar (cinacalcet HCl) This sectin fr Internal Use Only Fundatin ID: [ ] Distributr ID: [ ] Please cmplete each sectin t the fullest extent pssible. If an item des nt apply, please nte N/A. Return this cmpleted cnfidential applicatin t the address r fax number abve. The applicatin prcess can be initiated based n receipt f a faxed applicatin and prescriptin. Patient Infrmatin Patient s Name: Date f Birth: Sex: M F Scial Security Number: Is the Patient a US Citizen r Resident? Yes N Phne (Day): Mailing Address: City: State: ZIP Cde: Physician Infrmatin Physician Name: State License Number: Cntact Persn (ther than physician): Facility/Practice Name: Address (n PO bxes please): City: State: ZIP Cde: Telephne: FAX: Financial Infrmatin Current annual husehld grss incme $ Husehld size (required) - include applicant & number f dependents n Federal incme tax return: Patient Insurance Cverage: Primary Cverage Cmmercial Medicare Medicaid VA/DOD State Kidney Prgram Other Insurer (explain): Patient Insurance Cverage: Secndary/Supplemental Cverage Cmmercial Medicare Medicaid VA/DOD State Kidney Prgram Other Insurer (explain): Insurance Cmpany Name: Insurance Cmpany Name: Plicy Hlder Name: Plicy Hlder Name: Plicy Hlder s Date f Birth: Plicy Hlder s Date f Birth: Plicy ID Number: Plicy ID Number: Grup Number: Grup Number: Effective Date: Effective Date: Insurer Telephne: ( ) Insurer Telephne: ( ) Prescriptin Cverage: (under Primary) Prescriptin Cverage: (under Secndary/Supplemental) Prescriptin Benefit Name: Prescriptin Benefit Name: Telephne : ( ) Telephne : ( ) Cpay/Premium Assistance Fundatin Screening: Have yu applied fr and ENTER MEDICARE COVERAGE DETAILS (please circle): Medicare Part A: Yes N/A Denied Pending Effective: received c-payment r premium funding assistance? Yes: N: Medicare Part B: Yes N/A Denied Pending Effective: If yes, list amunt and status f award: Medicare Part D: Yes N/A Denied Pending Effective: Cpay Award Status: Pending Award Exhausted Funding Part D Plan Name: Telephne: ( ) Denied Funding Receiving Funding Please indicate all surces f incme by checking the apprpriate bx(es) belw: Emplyment Scial Security (SS) Benefits Supplemental Security Incme (SSI) Scial Security Disability Incme (SSDI) Other (explain): Page 5 f 7

6 Frm B: PATIENT FORM Patient s Name: Applicatin Declaratin My dctr has prescribed the applicable prescriptin drug fr me and I wuld like t receive the drug free f charge thrugh The Safety Net Fundatin (the Fundatin ). In rder t participate, I hereby certify that the financial/insurance infrmatin listed abve is accurate. I agree that this infrmatin can be prvided t the Fundatin, Amgen, and any agent f Amgen r the Fundatin authrized t perfrm services n behalf f the Fundatin. I understand that, in rder t determine my eligibility t participate in the Fundatin, the Fundatin needs infrmatin abut my family incme, and my health insurance. I agree t permit infrmatin abut me t be given t the Fundatin, Cvance, RxCrssrads, and Amgen t supprt my applicatin, which will include a verificatin f my cverage with my insurance cmpany, and t update my recrds t shw that I cntinue t qualify fr the Fundatin. I further authrize the Fundatin t prvide Amgen with infrmatin cncerning any assistance prvided t me by the Fundatin. I als understand that my infrmatin may be prvided t clinicians, scial wrkers, and family members if reasnably necessary t cmplete the applicatin r crdinate assistance. I understand that my assistance in the frm f free prduct is cntingent upn my ability t meet the eligibility criteria fr the prgram. I als understand that the Fundatin reserves the right at any time, and withut ntice, t mdify the applicatin frm; mdify r discntinue this prgram and its eligibility criteria; r terminate assistance. I wuld like t receive Kineret (anakinra) and/r Sensipar (cinacalcet HCl) free f charge frm The Safety Net Fundatin. I d nt have, nr am I eligible fr, any private r public health insurance ther than that listed abve. I d nt have, nr am I eligible fr, any ther frm f public assistance with my medical expenses. I certify that I will nt request reimbursement frm any insurance carrier r gvernment health benefit prgram fr any Kineret and/r Sensipar I receive frm the Fundatin. I certify that the abve infrmatin is crrect t the best f my knwledge. I understand that this infrmatin will nt be used fr any ther purpse unless I give written cnsent, the gvernment requires it, r The Safety Net Fundatin remves my name and any ther identifying infrmatin. I understand that The Safety Net Fundatin may change r stp this prgram with respect t any patient, r in its entirety, at any time. I als understand that, althugh Kineret and/r Sensipar may be given t me free f charge nw, this des nt mean I will be entitled t receive it free f charge indefinitely. I will nt sell, trade, r distribute Kineret and/r Sensipar given t me by The Safety Net Fundatin. I understand that The Safety Net Fundatin and RxCrssrads, r such ther distributr as the Fundatin may designate, may need t btain my medical recrds frm my physician and related infrmatin, including but nt limited t my name, Scial Security number, address, and date f birth, in rder t assure cntinuity f care and in rder fr me t receive Kineret and/r Sensipar. I authrize my physician t release t the Fundatin all medical recrds and related infrmatin that may be necessary r helpful t the prvisin f Kineret and/r Sensipar. I als authrize the Fundatin, RxCrssrads, and their agents, t release medical infrmatin and related infrmatin t each ther fr purpses f my health care and in rder fr me t receive Kineret and/r Sensipar. A phtcpy f this authrizatin will be as valid as the riginal. I understand that The Safety Net Fundatin, Cvance, and RxCrssrads may need t wrk with my scial wrker r ther dialysis center agent t case manage and crdinate care, including drug refills, n my behalf. I hereby grant authrity t (first/last name), (relatinship t patient) t act as my representative fr the purpse f crdinatin f therapy in The Safety Net Fundatin. This cnsent expires the latter part f 1 year after the date f executin r 1 year after the last date I receive prduct under the prgram. I understand that this infrmatin identifying me, which is prvided n Parts 1 and 2 f this applicatin, will nt be used fr any purpse ther than fr the Fundatin unless: *I give written cnsent, r * It is required by the gvernment, r *Amgen first remves my name and any ther identifying infrmatin. X Signature f Patient r Legal Representative X Date Relatinship if Other Than Patient Page 6 f 7

7 Frm A: PHYSICIAN FORM The Safety Net Fundatin Frm A: PHYSICIAN FORM 12-MONTH PROVIDER PRESCRIPTION FORM Physician Instructins: Please cmplete frm and fax r mail the entire applicatin packet (bth patient and physician frms) t the address r fax number belw. T: Frm: The Safety Net Fundatin PO Bx La Jlla, CA Phne: 888-SN-AMGEN ( ) Fax: Physician Name: SLN#: Cntact Persn (ther than physician): Facility/Practice Name: Address (n PO bxes please): NPI#: DEA#: City: State: Zip Cde: Telephne: FAX: Patient Infrmatin Patient s Name: Case number: Sex M F Scial Security Number: Date f Birth: Patient ID: Patient Dx: Phne (Day): Phne (Evening): Address: City: State: Zip Cde: Prescribing infrmatin (chse apprpriate medicatin): Physician Initials fr Kineret Prescriptin: Medicatin Dse Frequency Quantity Check One Kineret 100mg 1x/day 12-mnth supply (2-mnth supply per shipment) SimpleJect N/A N/A One (include with first shipment) Physician Initials fr Sensipar Prescriptin: Medicatin Dse Frequency Quantity Check One Sensipar Sensipar Sensipar 30 mg 60 mg 90mg daily 12-mnth supply (2-mnth supply per shipment I have prescribed the prduct indicated abve fr the referenced patient. My patient gave cnsent fr me t prvide this infrmatin. I understand that n third party r patient shuld be charged fr the prduct prvided by this prgram. I understand that n free prduct shuld be sld r distributed fr sale. X X Physician s Original Signature (stamps nt accepted) Date Cmpletin f this frm is part f the initial applicatin prcess and des nt guarantee enrllment in The Safety Net Fundatin. The Fundatin will review the cmpleted applicatin t determine the patient s eligibility. Page 7 f 7