megace pap.ai

PATIENT ASSISTANCE PROGRAM
P.O. BOX 42886 • CINCINNATI, OH 45242
Phone: 800-589-0841 Fax: 513-618-0058
Email: [email protected]
Physicians can apply online at www.RxHope.com
PATIENT ASSISTANCE PROGRAM INSTRUCTIONS
• Application must be completed and signed by the Healthcare Provider and Patient.
• Patient must submit Proof of Income.
• A prescription written for Megace ES 625mg/5mL must accompany the application.
ELIGIBILITY & REQUIREMENTS
• Patient can not have prescription coverage through any Private Insurance, State or Federal Program.
• Patient’s annual household income must be at or below 200% of the current Federal Poverty Level.
REORDERING MEDICATION
• A thirty day supply of Megace ES will ship to the Health Care Provider’s office.
• Before the patient is due for a refill, the Health Care Provider and the Patient must sign and submit a new application. Electronic
copies of the completed application can be obtained by calling the Megace ES Patient Assistance Program at 1-800-589-0841.
• A valid prescription for Megace ES 625mg/5ml MUST accompany each refill request.
• Medication is shipped within 5 to 7 business days.
Program Instruction Sheet
Version 3
10/09
PATIENT ASSISTANCE PROGRAM
P.O. BOX 42886 • CINCINNATI, OH 45242
Phone: 800-589-0841 Fax: 513-618-0058
Email: [email protected]
Physicians can apply online at www.RxHope.com
STEP ONE - To be completed by the Patient
PATIENT INFORMATION
Patient First Name _______________________________ MI __________ Patient Last Name _________________________________
Address _______________________________________________________________________________________________________
City _________________________________
State ____________ Zip Code _________________ Gender:
Phone ______________________ Date Of Birth (MM/DD/YYYY) ____________________ Marital Status:
Social Security #________________________
Are you a U.S. resident?
Yes
No
Male
S
Are you a Veteran?
M
Female
D
W
Yes
No
Number of persons in household ___________ Gross Annual Household Income $_________________________________________
Does the patient have any prescription coverage for Megace ES?
Is the patient enrolled in Medicare Part D?
Yes
No
Yes
No ____________________________________
If yes, please provide co-pay amount and insurance carrier
I certify that this information is complete and accurate to the best of my knowledge, and that I am unable to afford the medication requested. I understand that additional
information may be requested to process this application, but that all medical and financial information will be kept confidential, except otherwise required by law. I certify that
I shall not seek reimbursement for any medication dispensed as part of this program. I hereby authorize Strativa Pharmaceutical, Inc. to obtain and disclose information
from physicians, insurance companies and others as necessary to verify the information provided on this application.
Patient Signature ____________________________________________________________ Date ______ /_______ / _______
STEP TWO - To be completed by the Healthcare Provider
HEALTHCARE PROVIDER INFORMATION
DEA Number ____________________________ State License Number____________________________ Exp Date ______________
Physician Name ____________________________________________________________________ Designation ________________
Address _______________________________________________________________________________________________________
City ______________________________________________ State _______________________ Zip Code ______________________
Telephone _________________________ Fax ____________________________ Office Contact _____________________________
I verify that the information provided is complete and accurate to the best of my knowledge. Strativa Pharmaceutical, Inc. reserves the rights to request additional
information if needed and to change or discontinue this program at any time without notice. By signing this form, I certify that I am prescribing the aforementioned medication
for a patient participating in the patient assistance program. I understand that the medication prescribed below shall be sent to my office for dispensing to this patient, and I
certify that the medication requested shall only be used to treat this patient and I shall not seek reimbursement for this medication from any third party.
Healthcare Provider Signature ____________________________________________________
STEP THREE - To be completed by the Healthcare Provider
PRESCRIPTION INFORMATION
1 bottle
30-day supply
Date _______ / _______ / ________