Prescription Assistance Program

Prescription Assistance Program

Membership Enrollment Form Member Information First Name: MI: Last Name: DOB (mm/dd/yy): / / Social Security Number: - - Street Address: City: St: Zip: Telephone: Membership Fee(s) Non Refundable Enrollment Fee $ 25.00 Monthly Recurring Fee $ Recurring Fee Draft Date: 4 th 22 nd Initial Screening Questions Number of People In Household: Estimated Annual Income: $ Are You Enrolled In Medicare? YES NO E-mail Address: Your Medication(s) Insurance Status: (check any that apply) Insured No Insurance Inadequate MEDICATIONNAME(s) DOSAGE QTY NAME OF PRESCRIBER PRESCRIBER(s) PHONE # Payment Information Bank Draft - Checking Accounts Only Name of Account Holder: Name of Bank Routing # Account # LSSC AGENT CODE: Payment Authorization I authorize Lone Star Script Care to initiate debit entries electronically to my account indicated and I authorize the depository institution named above to debit same to such account. This authorization remains effective and in full force until Lone Star Script Care has received notification from me of its termination in such time and in such manner to afford Lone Star Script Care and the depository/institution a reasonable opportunity to act on it. Signature: Date: This is NOT insurance.

Welcome to Lone Star Script Care, an organization, helping Individuals and Families save money on their costly prescription medications. We are currently in receipt of your Patient Assistance Application that you recently completed through one of our Patient Advocates. In order to act as your advocate, we will need an information release so that your physician(s) can communicate directly with Lone Star Script Care and the various program sponsors for which we will be attempting to obtain your medications through. Please sign the enclosed forms and return to us as quickly as possible! We will be contacting your Physician(s) on a regular basis to complete this step and we are diligently working on your behalf for you. In most cases, these forms are pre-filled with your information and all that is required is your Physician(s) signature/verification of the prescription. Please be patient with the process. It can take up to 6 weeks before you will start to receive your medications and there are many steps that we have to go through in order to get you approved. The most difficult part in this process is obtaining the necessary forms back from your Physician. This step alone can take as long as 30 days to complete. We would also like to remind you that you are not paying us for your prescriptions and that upon approval of your application for assistance the individual program sponsor(s) will send you the medication(s) directly to you. As soon as we have the necessary forms back from the physician, we will check them for accuracy before submitting them directly to the applicable program sponsor(s) for consideration. As discussed, the whole process from start to finish can take as long as 30-60 days so it is important you remain patient. If you have any questions regarding the process, please do not hesitate to contact us. We are more than happy to assist you. Lone Star Script Care, PO Box 915, Oswego, NY 13126 Phone: (888) 962-0422 Fax: (888) 899-5685 Email: support@lsrxcare.com

Unlimited access to our patient concierge specialists via phone from 9am 5pm Eastern Standard Time and 24/7 online through our website. We facilitate enrollment in over 3,800 prescription assistance programs and continually update our formulary to include the most recently approved medication(s) Access to additional programs and resources to help lower your monthly prescription drug costs. We personally communicate with your healthcare providers to obtain signatures, written prescriptions and any additional information as needed to fulfill your medication orders. We handle all refills on your medication, working with your doctor and the individual program sponsor(s) who provide the medication. We complete and submit all paperwork directly to each program sponsor as well as keep constant communication with them to assure your account is in good standing. Adding medication or changing a dosage is as simple as making a phone call. One call to us does it all. Postage-paid envelopes are provided to each patient and doctor in order to return all requested information to us hassle free. There is no age limit; this is not a discount card; this is not an insurance product so there are no deductibles to worry about. Welcome to Lone Star Script Care!

PO Box 915, Oswego, NY 13126 (P) 1-888-962-0422 (F) 1-888-899-5685 support@lsrxcare.com - www.lsrxcare.com PATIENT INSTRUCTIONS (Q) PLEASE COMPLETE THE FOLLOWING STEPS STEP 1 STEP 2 Sign the enclosed Authorization. PLEASE SIGN WHERE HIGHLIGHTED. You must also provide some form of proof of income. ACCEPTABLE DOCUMENTS FOR YOUR PROOF OF INCOME CAN INCLUDE ANY OF THE FOLLOWING: Please DO NOT send bank statements showing deposits. The manufacturer of your medication will not process your application with a bank statement as proof of income. SOCIAL SECURITY AWARD LETTER SOCIAL SECURITY ANNUAL BENEFIT LETTER SOCIAL SECURITY END OF YEAR IRS FORM 1099 W2 FOR THE PREVIOUS TAX YEAR NOTICE OF UNEMPLOYMENT BENEFITS IRS FORM 1040 (FIRST PAGE ONLY) STEP 3 Gather the following documents together: NOTE: FAILURE TO INCLUDE ALL 3 REQUESTED ITEMS WILL DELAY YOUR PRESCRIPTION ASSISTANCE SIGNED AUTHORIZATION ACCEPTABLE PROOF OF INCOME COPY OF STATE ISSUED IDENTIFICATION (DRIVERS LICENSE etc.) STEP 4 Mail all documents to: For Faster Processing Fax To: LSSC, PO Box 915, Oswego, NY 13126 1-888-899-5685

Please read all policies and initial in the designated boxes. If you do not initial ALL boxes, we cannot process your enrollment. Service: I hereby grant and authorize any medical facility, hospital, provider, insurance company, doctor, pharmacy or any other entity that has or retains medical records or knowledge of medical records to release such information upon request to LSSC (LSSC) for the purpose of applying for and my continued enrollment in various Prescription Assistance Programs. I also hereby authorize LSSC to act on my behalf and to sign applications for patient assistance programs by hereby granting to LSSC a limited power of attorney for the specific purposes of enrolling me in patient assistance programs with the applicable pharmaceutical programs and any related activities to process my enrollment. I permit all/any Patient Assistance Programs to speak/write to LSSC concerning my enrollment/ application. Furthermore I permit LSSC to sign any document(s) related to my enrollment/application on my behalf. LSSC will be acting as my personal representative for the purposes of my enrollment/application to various prescription assistance programs. I understand this authorization can be revoked at any time by me by providing a signed letter of cancellation to LSSC as described in the fees section. LSSC is a fee-based medication advocacy service that assists patients in enrolling in applicable prescription assistance programs. The medications themselves are offered by various programs, pharmacies and pharmaceutical companies through their patient assistance programs at no cost to the eligible applicant. I also understand and acknowledge that it is each individual program who makes the final decision as to whether I qualify for their assistance program(s). I understand that (LSSC) reserves the right at any time, and without notice, to modify the application form, to modify or discontinue this or any program: and to terminate assistance. I understand that completing this enrollment does not ensure that I will qualify for this program. Medication(s) are shipped directly from the pharmaceutical companies and/or participating pharmacies and delivered either to your home or physician s office, depending upon the program delivery guidelines. I also understand LSSC reserves the right to rescind, revoke, or amend its services at any time. LSSC does not guarantee your approval for patient assistance programs; it is up to each applicable program to make the eligibility determination. Each program independently sets its own eligibility criteria and determines which products are included in their assistance programs. Medications covered are subject to change at any time. In some cases generics will be substituted for brand name medication(s) where available and may be shipped from the USA, Canada, United Kingdom, India, Australia or New Zealand. LSSC assembles and submits your application to the applicable program but does not participate in the review process to determine which applicants are eligible. The role of LSSC, its affiliated companies, and its subcontractors shall be limited to administrative functions, including data entry and verifying the accuracy and completion of eligibility and enrollment information contained in this application form. With respect to my applications, I understand that my physician and the dispensing pharmacy will be responsible for the information contained in this application form. I authorize LSSC to forward my applications to various assistance programs on my behalf. LSSC is not acting as a dispensing pharmacy. LSSC is not responsible for checking or verifying any information contained in this application, including but not limited to, allergies, medical conditions or other medications being taken by the patient. LSSC will use all reasonable commercial efforts to enroll the client in the various programs offered by companies for the medications prescribed by the client's physician. By initialing here you acknowledge that you have read, understood and agree to be bound by the above paragraphs. Fees: Prescription Assistance Programs (PAPS) can modify or discontinue programs without notice. PAP's are available to all qualified individuals FREE of charge, and I am solely responsible for paying LSSC for their services in the processing and filing of applications for PAP programs and NOT for the medications. I have paid and agree to a non-refundable fee of $25.00 payable to LSSC to assist me in applying for free medications and a monthly membership fee per medication for helping me obtain free medication. Any non-payment of fees may incur additional costs, including reasonable collection costs as determined by LSSC. I understand this is a service based contract and is NOT INSURANCE. My monthly membership fee will be debited on the 4th or 22nd day of every month. My first monthly membership fee will be due no later than the month following my initial enrollment with LSSC. I understand that my monthly membership fee may be due prior to actually receiving medication. If I am applying for an assistance program in which I have to qualify based on my income the monthly membership fee will be $20.00 per medication, per month. If I am applying for assistance in which there are no qualification requirements, then my monthly membership fee will be based on a tiered level. LSSC will confirm the amount of the monthly membership fee with prior to billing me. This can include any notification by email or by phone. In the event you are deemed ineligible for assistance (Qualified) of your medication we will gladly refund the monthly membership fee(s) paid for that particular medication(s) We reserve the right to request a copy of the denial letter provided to you by the pharmaceutical company to be able to provide a refund. You hereby acknowledge that you are not paying for medication(s) through the Lone Star Script Care's Prescription Assistance Eligibility: I understand that completing this form does not guarantee that I will qualify for any particular program. All of the information I have/will provide and the copies of the income documents or other information about me that I may provide are complete and true. I verify that the information provided in my application(s) are correct and accurate. I agree to provide LSSC with all requested documentation necessary to apply for the various PAP programs, including, but not limited to proof of income, prescriptions, Doctor's signatures and customer's signature on all applications, copy of Medicare card and/or insurance information, tax documents, etc. LSSC and its agents may ask for additional documents and information at any time, even if I am already enrolled to help me with free medicine if I am enrolled to help me with free medicine if I am enrolled. I affirm that the information provided on this form is complete and accurate. If you determine the information was not correct at the time you provided it to Lone Star Script Care LLC, nor if the Program; rather I am paying for the administrative service of ordering, managing, tracking and refilling medications received through this program. I hereby authorize LSSC and to debit the account provided during my initial enrollment for all administrative service fees described in this Fees section. I also agree to pay any associated fees should my EFT (electronic fund transfer) be returned unpaid by my financial institution. As a minimum, this fee will be $25.00 for each time your payment is returned to us by your financial institution. I hereby acknowledge, consent and agree this agreement is for twelve (12) months commencing on the date I sign below and will automatically be renewed for twelve (12) month terms thereafter. You may terminate this agreement at any time by providing a signed letter of cancellation. Cancellations take up to 30 days to process. Upon termination you agree to be financially responsible for any outstanding balances. In the event you are deemed ineligible for assistance by the manufacturer(s) of your medication(s) we will gladly provide a refund of the monthly membership fee(s) paid for that particular medication(s). We reserve the right to request a copy of the denial letter provided to you by the pharmaceutical company to be able to provide a refund. Due to the service-based nature of this program, cancellation by me will not result in a refund. I understand that refunds are only available in the event I am denied assistance by the applicable program sponsor(s) By initialing here you acknowledge that you have read, understood and agree to be bound by the above paragraphs. information was accurate but is no longer accurate, you will immediately notify LSSC in writing by providing the correct information. I currently have inadequate and/or no prescription drug coverage for the medication(s) I am requesting assistance with. You further agree to indemnify and hold LSSC, its agents, employees, and successor and assigns harmless against any and all damages including legal fees and costs arising from participation in this program. It will take approximately 4-6 weeks to start receiving your first supply of medication(s). I understand that completing this enrollment does not ensure that I will qualify for this program. I understand this is a service based contract and is NOT INSURANCE and that I am entering into a membership based program and that I should not stop with my current method of obtaining my medications until I have been approved for assistance. By initialing here you acknowledge that you have read, understood and agree to be bound by the above paragraphs. Privacy: We value our patients and make extreme efforts to protect the privacy of our patients personal information. Patient information is processed for order fulfillment only and for no other purpose. Patient information, including all patient health information and personal information, will never be disclosed to any third party under any circumstances. All information given to LSSC, its agents, employees, successors and assigns will be held in the strictest confidence. PATIENT NAME PATIENT SIGNATURE DATE Lone Star Script Care LLC, PO Box 915, Oswego, NY 13126 Tel: 1-888-962-0422 Fax: 1-888-899-5685