Enrollment Application for the Novartis Patient Assistance

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Information
Enrollment Application for the Novartis Patient Assistance Foundation, Inc.
P.O. Box 52029, Phoenix, AZ 85072-2029 ■ Phone: 1-800-277-2254 ■ Fax: 1-855-817-2711
Dear Patient and Health Care Professional:
Thank you for your interest in the Novartis Patient Assistance Foundation, Inc.
To be eligible for the Novartis Patient Assistance Foundation, Inc. patients must:
• Be a U.S. resident
• Meet the income requirements and
• Have no private or public prescription coverage
What to do:
Step 1 – Complete and sign Patient Section (page 2)
Step 2 – Attach copies of all required financial documentation
Step 3 – Your Doctor completes and signs Prescription Section (page 3)
Step 4 – Mail or fax form with documentation
The following products are available:
AFINITOR® (everolimus) Tablets for
Oral Administration
AFINITOR DISPERZ™ (everolimus) Tablets for
Oral Suspension
ARRANON® (nelarabine)
ARCAPTA™ NEOHALER™ (indacaterol
inhalation powder)
ARZERRA® (ofatumumab)
COARTEM® (artemether and lumefantrine)
COSENTYXTM (secukinumab)
ENTRESTOTM (sacubitril/valsartan)
EXJADE® (deferasirox)
EXTAVIA® (Interferon beta-1b)
FARYDAK® (panobinostat) Capsules
FOCALIN® XR (dexmethylphenidate hydrochloride)
GILENYATM (fingolimod)
GLATOPA™ (glatiramer acetate injection)
GLEEVEC® (imatinib mesylate)
HYCAMTIN® (topotecan hydrochloride) for Injection
HYCAMTIN® (topotecan) capsules
ILARIS® (canakinumab)
JADENU® (deferasirox) Tablets
LAMISIL® Oral Granules (terbinafine hydrochloride)
LEVOLEUCOVORIN Injection
MEKINIST® (trametinib)
MYFORTIC® (mycophenolic acid)
NEORAL® (cyclosporine)
ODOMZO® (sonidegib)
OMNITROPE® (somatropin [rDNA origin] for injection)
PROMACTA® (eltrombopag)
RECLAST® (zoledronic acid)
SANDIMMUNE® (cyclosporine)
SANDOSTATIN LAR® Depot (octreotide acetate)
SIGNIFOR® (Pasireotide)
SIGNIFOR® LAR (Pasireotide) Injection
TAFINLAR® (dabrafenib)
TASIGNA® (nilotinib)
TEGRETOL® (carbamazepine USP)
TEGRETOL®-XR (carbamazepine extended-release tabs)
TOBI® (tobramycin inhalation solution USP)
TOBI®PodhalerTM (tobramycin inhalation powder)
TRILEPTAL® (oxcarbazepine)
TYKERB® (lapatinib)
TYZEKA® (telbivudine)
VOTRIENT® (pazopanib)
ZOMETA® (zoledronic acid)
ZORTRESS® (everolimus)
ZYKADIA™ (ceritinib)
Patient Section
Enrollment Application for the Novartis Patient Assistance Foundation, Inc.
P.O. Box 52029, Phoenix, AZ 85072-2029 ■ Phone: 1-800-277-2254 ■ Fax: 1-855-817-2711
Patient’s Name: ________________________________________
Address: ______________________________________________
City: _____________________________ State: _______________
Zip: ________________ Phone: ___________________________
FINANCIAL INFORMATION: Attach a copy of
your household’s most recent year tax returns
(1040, 1040EZ, 1099, paycheck stubs, bank
statement, unemployment check, 4506T, etc.)
Do not send original documents with your application.
Cell Phone: ____________________________________________
Total # of People in the home (including self,
please add all those who are living with you)
US Resident: ¨ Y ¨ N Gender: ¨ M ¨ F Veteran: ¨ Y ¨ N
¨1
Disabled: ¨ Y ¨ N (Status as deemed by social security)
# of Children: _______ # of Adults: ________
Social Security/Green Card ID No
List all sources of Gross Monthly Income:
Salary/Wages (All Sources):
$_________________
Pension/Retirement:
+ $_________________
Social Security:
+ $_________________
Disability:
+ $_________________
Unemployment Benefits:
+ $_________________
Alimony/Child Support:
+ $_________________
Total Gross Monthly
Household Income
= $_________________
(required):
______________
Date of Birth: _____________ Product:____________________
Caregiver/family member: _____________________________
Address: _______________________________________________
City: _____________________________ State: ________________
Zip: ________________ Phone: ____________________________
¨2
¨3
¨4
¨5
¨ 6 or more
PATIENT INSURANCE INFORMATION: Please include a copy of the front and back of your Prescription Card and Insurance Card (required)
Medical Coverage
Medicare Part A
Identification No.
Phone Number
¨N
¨N
¨N
¨N
(______) ________-________
Medicaid
¨Y
¨Y
¨Y
¨Y
State Elderly Drug Assistance
¨Y ¨N
(______) ________-________
State Children Health Insurance
¨Y
¨Y
¨Y
¨Y
¨Y
(______) ________-________
Medicare Part B
Medicare Part D
Veterans Assistance
Private Insurance
Other
Did Medicare pay for your transplant?
¨N
¨N
¨N
¨N
¨N
Effective Date
(______) ________-________
(______) ________-________
(______) ________-________
(______) ________-________
(______) ________-________
(______) ________-________
(______) ________-________
Read & Sign Patient Authorization
I give permission for my doctor(s) and their staff to disclose my personal information, including information about my insurance, prescription, medical condition
and health (“Health Information”) to the Novartis Patient Assistance Foundation, Inc. (the “Foundation”) so that the Foundation can decide if I am eligible for the
Novartis Patient Assistance Program (“PAP”); operate the PAP and the Foundation; send me information about PAP and other programs that might help me pay for
my medicines; send my information to other programs that might help me pay for my medicines; ask me for financial, insurance and/or medical information and
share my information as required or permitted by law. I give permission to the Foundation to use information on this Application and any other information I give
to the Foundation for these same reasons. I also give the Foundation permission to share my Health Information and other information with people and companies
that work with the Foundation; government agencies, including the Centers for Medicare and Medicaid Services; insurance companies, including Medicare Part D
plans; my doctor(s) and other people, or institutions who are involved in my healthcare, such as pharmacies and hospitals; other organizations that might help me
pay for my medication. I promise that any information, including financial and insurance information that I provide to the Foundation are complete and true and
unless I have said something different in this application, I have no drug insurance coverage, which includes Medicaid, Medicare or any public or private assistance
programs or any other form of insurance. If my income or health coverage changes, I will call the PAP at 1-800-277-2254. I know that the Foundation may change or
end the PAP at any time. I know that if I do not sign this form, I will not be able to participate in the PAP, but this will not affect my ability to get medical care, seek
payment for this care or affect my enrollment or eligibility for insurance. I know that I can cancel this permission at any time by calling the PAP at 1-800-277-2254.
If I do, then I will not be able to stay in the PAP. I understand I have the right to receive a copy of this form.
Patient or Legal Guardian Signature (required): _______________________________________________ Date: __________________
Prescription Section
Enrollment Application for the Novartis Patient Assistance Foundation, Inc.
P.O. Box 52029, Phoenix, AZ 85072-2029 ■ Phone: 1-800-277-2254 ■ Fax: 1-855-817-2711
HEALTH CARE PROFESSIONAL (HCP) OFFICE INFORMATION: To be completed by the HCP.
HCP Full Name: ______________________________________________________________________________________________
Address: __________________________________________________________________________________________________
City: ______________________________________________ State: ________________________ Zip: ____________________
Phone: ____________________________________________ Fax: __________________________________________________
DEA/State License # : ______________________________ NPI #: ________________________________________________
Patient Coordinator/Nurse Advocate: ______________________________________________________________________
Address: __________________________________________________________________________________________________
City: ______________________________________________ State: ________________________ Zip: ____________________
Phone: ____________________________________________ Fax: __________________________________________________
Patient’s Full Name: _________________________________ Patient’s Date of Birth: _________________________________
Please list any other medications the patient is currently taking: ¨ None ____________________________________
Product, Pen, Syringe, Cartridge: ______________________________ Strength: _____________ Quantity: _____________
Directions: ________________________________________________________________________________________________
Refills: One year or: ________________________________ Date of transplant (if applicable): ____________________________
Please list patient’s allergies: ¨ No known ___________________________________________________________________
Physician Signature (required): _____________________________________________________________________________
¨ ________________________________________________ ____________________________________________________
Substitutions permitted
Date (required)
¨ ______________________________________________________________________________________________________
Dispensed as written
*Note: If required by your state (ie., NY & DE), please fax an original Prescription blank.
Read & Sign HCP Authorization
My signature below certifies that the person listed above is my patient for whom I have prescribed the drug identified
above. For the purposes of transmitting this prescription, I authorize Novartis Pharmaceuticals Corporation, and its affiliates, business partners, and agents, to forward as my agent for these limited purposes, this prescription electronically, by facsimile, or by mail to a dispensing pharmacy chosen by the above-named patient. I certify that any medications
received from Novartis (as defined above) in connection with this application will be used only for the patient named
on this form. These medications will not be offered for sale, trade, or barter. Additionally, no claim for reimbursement
will be submitted concerning these medications to Medicare, Medicaid, or any third party, nor will any medications
be returned for credit. I acknowledge that I have assisted the patient in enrolling in the Novartis PAP exclusively for
purposes of patient care and not in consideration for, expectation of, or actual receipt of remuneration of any sort.
I also agree that Novartis has the right to contact the patient directly to confirm receipt of medications, and I understand that Novartis may revise, change, or terminate this program at any time. Finally, to the best of my knowledge, the
patient listed above meets Novartis’ eligibility criteria for the PAP.
Prescriber Signature (required): _________________________________________________ Date:____________________
Checklist
Enrollment Application for the Novartis Patient Assistance Foundation, Inc.
P.O. Box 52029, Phoenix, AZ 85072-2029 ■ Phone: 1-800-277-2254 ■ Fax: 1-855-817-2711
HCP did you:
Patient did you:
¨
¨
¨
¨
Fill out the Patient Section?
Sign the bottom of the Patient Section?
If you have checked all the boxes above,
you are ready to submit the form!
Complete and sign Patient Section?
A
ttach copies of all required financial
documentation?
¨
H
ave your Doctor complete and sign the
Prescription Section?
¨
Mail or fax form with documentation?
If you have checked all the boxes above,
you are ready to submit the form!
Follow these steps to complete your application process:
1. Mail pages 2 and 3 of the Application with Financial Documentation to:
NOVARTIS PATIENT ASSISTANCE FOUNDATION, INC.
P.O. Box 52029,
Phoenix, AZ 85072-2029
OR
2.Fax pages 2 and 3 of the Application with a Health Care Professional Fax Cover Sheet
and Financial Documentation to:
Fax: 1-855-817-2711
• If the application is faxed, it must be sent from the Health Care Professional’s office.
We will review and process your application once we receive the completed application with
supporting financial documentation. You will receive a letter about your status soon.
If you have any questions, please call a Novartis Patient Assistance Foundation, Inc. representative
at 1-800-277-2254, Monday through Friday, 9:00 am to 6:00 pm EST.
June 14, 2015
00536-0616
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