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Microsoft word - frm100 amedra pap application 05 08 13 _4_

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Mail or Fax to: Amedra Cares
Patient Assistance Program

PO Box 66553
St. Louis, MO 63166-6533
Phone 1-877-908-8583 Fax 1-877-908-9987

Thank you for your interest in the Amedra Cares Patient Assistance Program (PAP) for ALBENZA® (albendazole) and DARAPRIM® (pyrimethamine). Attached is a copy of the application form. To be eligible to receive free medicine from Amedra Cares PAP, patients must be U.S. residents, must not have prescription drug coverage, and total household income must meet the program eligibility requirements. APPLICATION INSTRUCTIONS FOR PRACTITIONERS - REQUIRED
1. Complete Practitioner Information Section 1. Provide phone, fax, and DEA or State License number. 2. Sign application
3. Have patient fully complete the Patient Information Sections 2, 3, and 4 and sign the application.
4. Attach a prescription with the application.
5. Fax or mail the application, financial documentation, and prescription to:
Amedra Cares
Patient Assistance Program
PO Box 66553
St. Louis, MO 63166-6553
Phone 1- 877-908-8583 Fax 1-877-908-9987
Only faxes sent from the prescribing physician’s office along with physician’s fax cover sheet and fax banner
can be accepted.
b. Insurance Information (Section 3) c. Income Information (Section 4) 2. Sign the application 3. Attach a copy of last year’s tax return or other records for proof of income. Some examples are IRS Forms 1040, 1040A, 1040EZ,W2, 1099PR, and 1099 Social Security Statement If you did not file a tax
return, please attach an IRS Form 4506-T, which shows that you did not file.
NOTE: An application and prescription is needed for each family member if applicable.
If approved, patients are eligible to receive free medication for up to one year. Medications will be sent to the patient’s home. New prescription needed for each medication order.
For questions regarding this program or application, please call us at 1- 877-908-8583, Monday through Friday,
8:00 AM to 5:00 PM CST.
Mail or Fax to: Amedra Cares
Patient Assistance Program (PAP)

PO Box 66553,
St. Louis, MO 63166-6533
Phone 1-877-908-8583 Fax 1-877-908-9987

State License # (or DEA#, if required)
To the best of my knowledge, this patient has no coverage (including Medicare, Medicaid, VA or any other public programs) for this prescription. I verify
that to the best of my knowledge the information provided is complete and accurate.
Original Signature of Prescribing Healthcare Provider (Required to process application)

SECTION 2 - PATIENT INFORMATION (Please print clearly)
Note: Upon approval, medication will be sent to the patient’s address
Number of people in household (include self): TOTAL GROSS MONTHLY INCOME

Do you have a State Patient Assistance Program?  Yes  No Do you have VA or military benefits?  Yes  No Do you have private prescription drug coverage?  Yes  No SECTION 4 - PATIENT INCOME INFORMATION
Note: Attach Proof of Income (Examples: Federal Tax Return, IRS Form 1040, 1040EZ, 1099, Social Security or Disability Statement)
Informed Consent and Authorization for Use and Disclosure of Health Information for Patient Assistance Program
I understand that completing this form does not ensure that I will qualify for the Amedra Patient Assistance Program (“Program”). I represent that the information provided in this qualification form is complete and accurate. I agree to notify and shall be responsible for notifying the Program Administrator for the Program if I obtain coverage through another source or if I no longer meet the income criteria for the Program. I authorize my healthcare provider to disclose medical information and related information to Amedra Pharmaceuticals, (“Company”), including Express Scripts Specialty Distribution Services, Inc. any of its subsidiaries or affiliates (the “Program Administrator”), and I authorize Company to obtain and disclose information as deemed necessary to verify the accuracy and completeness of this application and to provide services available through the Program. I also authorize Company to release medical information and related information to the Centers for Medicare and Medicaid Services (“CMS”) for purposes of administering the Program. I understand that personal identifying information provided on this form will be available to Company and its agents for the purpose of administering the Program. I understand that Company reserves the right at any time and without notice to me to modify and/or discontinue any or all of the Program, including modification of eligibility criteria and immediate termination of assistance provided by the Program. If I decide to terminate my authorization for my health care providers and my insurers to disclose my information to Company, I shall notify Company in writing at Amedra Patient Assistance Program, P.O. Box 66553, St. Louis, Missouri 63166-6553 that I no longer provide such authorization which termination shall be effective upon Company’s receipt of such notification. I understand that I have a right to obtain a copy of the information my health care providers or insurers have provided to Company upon request to Company. I understand that I may decline to sign this form and decline being considered for the Program. I understand that signing this form does not affect the way my health care providers or insurer will provide me with their respective services. I understand that this form expires in one year or when my eligibility to the program expires. Patient’s Signature
Don’t forget to include ORIGINAL prescription(s) signed by Prescribing Healthcare Provider


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