Medication Assistance Program Application

Please complete this form in its entirety.

Note: We cannot guarantee that you will qualify for the Medication Assistance Program, even if you appy. Once you send in your application, we will check all the information and may ask for additional information or proof of income.

Patient Information

First Name *

Last Name *

Phone

Date of birth *

SSN (optional)

Address

Street Address *

City *

State *

Postal code *

I permit Reedsburg Area Medical Center to speak with the following person and/or organization about the information on this application and the status of my application request. These people can provide or receive your personal information as necessary until you terminate their authority. Their authority will not automatically terminate once we process your application. Their authority will terminate at the end of your enrollment period.

Patient Representative / Organization 1

Relationship to Patient

Phone

Prescription Insurance Information

Do you have any form of prescription drug insurance?

Yes

If yes, please provide the information below:

Plan Name

Member ID

Phone Number

Insurance

Employer-supplied or commercial / private drug insurance

VA or Military Benefits

Medicaid Prescription Drug Coverage

Medicare Part B

Low Income Subsidy (LIS/ Extra Help)

Medicare Part D (Prescription Drug Coverage)

Please include a copy of your insurance cards

Medicare Beneficiary Number (MBI) number found in your Medicare Card

Family Information

List family members in your household, including you. "Family" includes people related by birth, marriage, or adoption who live together.

Family Size

Name 1 *

Date of Birth *

Relationship to Patient *

If 18 years old or older: Employer(s) name or source of income *

If 18 years old or older: Total gross monthly income (before taxes) *

Also applying for financial assistance? *

Yes

Do you want to add another family member's details? *

Yes

Name 2

Date of Birth

Relationship to Patient

If 18 years old or older: Employer(s) name or source of income

If 18 years old or older: Total gross monthly income (before taxes)

Also applying for financial assistance?

Yes

Do you want to add another family member's details?

Yes

Name 3

Date of Birth

Relationship to Patient

If 18 years old or older: Employer(s) name or source of income

If 18 years old or older: Total gross monthly income (before taxes)

Also applying for financial assistance?

Yes

Do you want to add another family member's details?

Yes

Name 4

Date of Birth 4b

Relationship to Patient 4c

If 18 years old or older: Employer(s) name or source of income 4b

If 18 years old or older: Total gross monthly income (before taxes) 4b

Also applying for financial assistance? 4b

Yes

Do you want to add another family member's details? 4b

Yes

Name 5

Date of Birth 5b

Relationship to Patient 5c

If 18 years old or older: Employer(s) name or source of income 5b

If 18 years old or older: Total gross monthly income (before taxes) 5b

Also applying for financial assistance? 5b

Yes

Do you want to add another family member's details? 5b

Yes

Name 6

Date of Birth 6b

Relationship to Patient 6c

If 18 years old or older: Employer(s) name or source of income 6b

If 18 years old or older: Total gross monthly income (before taxes) 6b

Also applying for financial assistance? 6b

Yes

You must include proof of income with your application

All family members 18 years or older must disclose their income. If you cannot provide documentation, you may submit a written signed statement describing your income. Please provide proof for every identified source of income. The more documentation you provide, the more accurately we can calculate any potential discount.

Examples of proof of inclome include:
-Current pay stubs (3 most recent) OR

-Annual SSA/SSI letter or bank statement, OR
-Written, signed statements from employers or others, OR

-Approval/denial of eligibility for Medicaid and/or state-funded medical assistance, OR

-Approval/denial of eligibility for unemployment compensation, OR

-If you have no proof of income or no income, please attache an additional page with an explanation.

NOTE: Last year's income tax return, including schedules, if applicable, may be requested for additional verification.

Attach File 1 (MAP)

Attach File 2 (MAP)

Attach File 3 (MAP)

Attach File 4 (MAP)

Attach File 5 (MAP)

Attach File 6 (MAP)

Attach File 7 (MAP)

Attach File 8 (MAP)

Patient Authorization to Share Health Information

I give permission to my health care practitioners, my health plan, and insurers to give health and other information about my use or need medications provider under the Medication Assistance Program to Reedsburg Area Medical center in charge of administering the Patient Assistance Program. I understand that:

-People with the Medication Assistance Program, Reedsburg Area Medical Center (RAMC), or others working on behalf of RAMC may see and use my information for administering the Medication Assistance Program.

-RAMC or the Medication Assistance Program may give information to the Centers for Medicare & Medical Services (CMS) to confirm my Medicare Part D enrollment status.

-My information will include my name, address, income, SSN, prescription coverage, prescription for medication (s), financial documents and insurance records.

-My information will be used to see if I meet the requirements to participate in the Medication Assistance Program.

-The Medication Assistance Program, RAMC, and others helping them will keep my information private, but that the federal privacy laws may no longer protect my information once it is disclosed. The Medication Assistance Program will only use my information as described in this form.

-If I do not sign this form, I will not be able to participate in the Medication Assistance Program.

By signing below, I acknowledge I have read and agree to the Patient Authorization to Share Health Information above.

Signature of Applicant or Parent/Legally Authorized Representative

Relation to Patient

Patient

Parent

Legally Authorized Representative of Patient

Patient Name

Signature

Clear

Date of Signature

Patient Certification

I understand that:

-Reedsburg Area Medical Center will only use my information to decide if I qualify for the Medication Assistance Program.

-Reedsburg Area Medical Center may verify information by reviewing credit information and obtaining information form other sources to assist in determining eligibility for the Medication Assistance Program.

-My application might not be approved.

-RAMC Pharmacies may change or end the Medication Assistance Program or terminate my enrollment in the Medication Assistance Program at any time.

-RAMC Pharmacies does not charge a fee to apply for participation in the Medication Assistance Program.

-I need to complete and submit an entire application, including financial documentation, to continue to receive free drugs covered through this program.

I agree that:

-My application is complete and accurate. I have been truthful about my insurance coverage and income.

-RAMC Pharmacies can contact me by phone or text about the Medication Assistance Program or other services that might interest me for which I may be eligible.

-I will promptly provide documentation supporting the information I have provided in this application (e.g., income verification documents) within 15 days of discharge. Failure to promptly provide complete and accurate documentation will result in immediate removal from the Medication Assistance Program.

If my application is approved:
- I will notify Reedsburg Area Medical Center of changes to my income or insurance status.
-I will not submit any claim for reimbursement to any third party or government insurer for any product provided to me through the Medication Assistance Program.
-If I have Medicare Part D coverage, I will not seek to have the cost/value associated with the medication I receive through the Medication Assistance Program counted as out-of-pocket costs for prescription drugs.
-I will not sell, trade or transfer any medications I receive through the Medication Assistance Program.

By signing below, I acknowledge I have read and agree to the Patient Certification Information above.

Relation to Patient

Patient

Parent

Legally Authorized Representative of Patient

Patient Name

Signature - Patient Certification

Clear

Date of Signature