Microsoft word - 2011 abilify application_final_110225.doc

BRISTOL-MYERS SQUIBB PATIENT ASSISTANCE FOUNDATION, INC.
ABILIFY PATIENT ASSISTANCE PROGRAM
P.O. Box 8309
Somerville, NJ 08876
Phone: (800) 736-0003
Fax: (866) 598-5561
Thank you for your interest in the Bristol-Myers Squibb Patient Assistance Foundation (BMSPAF) Program. Enclosed you will find the application form you had requested. To participate in our program, it is important that you complete all requested information and sign where indicated. Incomplete applications will be returned. PATIENT REQUIREMENTS:
9 Must live in the U.S., Puerto Rico or the U.S. Virgin Islands and cannot have any form of public or private prescription drug coverage such as Medicaid or Medicare Part D. 9 Complete and sign the Patient Information section. 9 Attach a photocopy of the ANNUAL household income (Federal tax form (1040), social security income (SSA 1099), pensions, interest, retirement, child support). INCOME ELIGIBILITY CRITERIA REQUIREMENTS:

Total household income must not exceed income criteria listed below (amounts may change annually):
Persons in Household
48 Contiguous States and D.C.
1 $27,225
2 $36,775
3 $46,325
4 $55,875
5 $65,425
For each additional person, add
$9,550 $11,950

HEALTHCARE PROVIDER REQUIREMENTS:

9 Complete and sign the Healthcare Provider section. There is no need to include a prescription. 9 Provide your State License Number in order to process the application. 9 Complete the section for RX instructions; including drug name, strength and quantity per day 9 List a shipping address for your physical office address. Cannot ship to a patient’s home or a P.O. Box. 9 Complete the ENTIRE application. When requesting a change of dosage for an existing patient, indicate “YES” on the “change to dosing schedule” portion of the application and provide the new prescription instructions.
SUBMIT COMPLETED APPLICATIONS BY SELECTING ONE OF THE FOLLOWING OPTIONS:

9 MAIL: Abilify Patient Assistance Program 9 FAX: 1-866-598-5561 (Please DO NOT fax multiple submissions of the application) You will be notified by mail upon completion of our review and evaluation. Please note, program rules are subject to change
without notice. If you have questions or need further assistance, please call 1-800-736-0003, between 9:00 AM and 6:00 PM
Eastern Time, Monday through Friday.

Sincerely,
Bristol-Myers Squibb
Patient Assistance Foundation, Inc.
Enclosure
BRISTOL-MYERS SQUIBB PATIENT ASSISTANCE FOUNDATION, INC.
ABILIFY PATIENT ASSISTANCE PROGRAM
P.O. Box 8309 | Somerville, NJ 08876 | Phone: (800) 736-0003 | Fax: (866) 598-5561

PATIENT INFORMATION
First Name: MI: Last Name: Date of Birth: / / Street Address where you live: City: State: Zip Code: Mailing address (if different from above) City: State: Zip Code: PATIENT ELIGIBILITY INFORMATION – ATTACH PROOF OF ANNUAL HOUSEHOLD INCOME (REQUIRED)
TOTAL ANNUAL HOUSEHOLD INCOME $
(include all annual income, Wages, Social Security, Pension, Disability, Interest Earned on Savings, etc.)
*If you have indicated no income ($0), your application may be subject to audit or request for additional documentation.
Household Size (number of persons living in the home): Have you applied for Medicaid in the past and been I attest that the above information is complete and accurate. I attest that I have no prescription insurance coverage, including Medicaid, Medicare or any other public or private program and I have insufficient financial resources to pay for the prescribed therapy. By my signature, I authorize the release of information about me and my medical condition to the Bristol-Myers Squibb Patient Assistance Foundation (BMSPAF), and/or their agents. I authorize the BMSPAF, and/or their agents to use and disclose such information for the assessment of my eligibility for, enrollment into the BMSPAF and administration of the BMSPAF, which may include contacting my insurer, public funding programs, social workers, advocacy organizations, healthcare providers, or other persons or entities the BMSPAF may deem appropriate, to release all medical records or requested information bearing on my eligibility to and benefits under the program. Additionally, I agree that at any time during my enrollment, the BMSPAF may request additional documentation to authenticate the statements made on my application. The BMSPAF and/or their agents agree not to disclose any information to any third party except as authorized by me or as required by law. I understand and acknowledge that this assistance is temporary and that this program may be changed or discontinued at any time without notice. I understand that the BMSPAF, and/or their agents are relying on this information. Patient’s Signature: Date: _____________________ Advocate Signature: Date: ______________________ HEALTHCARE PROVIDER INFORMATION TO BE COMPLETED BY THE PRESCRIBING PRACTITIONER
First Name: Last Name: Professional Designation: Shipping Address 1: (cannot ship to P.O. Box) Contact Name: Phone Number: ( ) Fax: ( ) REQUESTED MEDICATION (PLEASE CHOOSE):
Abilify Oral Solution 150 mL Abilify 2mg Abilify 5mg
Abilify 10 mg
Abilify 15mg
Abilify 20 mg
Abilify 30 mg
____ Qty / Day ____ Qty / Day ____ Qty / Day ____ Qty / Day ____ Qty / Day ____ Qty / Day ___ Qty / Day Abilify 10mg DISCMELT ® Abilify 15mg DISCMELT ® Is this a change in dose schedule for an existing BMSPAF member? YES
I represent that any information I have provided about this patient is complete, accurate and consistent with applicable privacy laws and regulations, and I understand that the BMSPAF, and/or their agents are relying on this information. To the best of my knowledge, this patient has no prescription insurance coverage, including Medicaid, Medicare or other public or private programs. I acknowledge and agree not to submit an insurance claim or other claim for payment to any third-party payor (private or government) for the medication. I understand that BMSPAF reserves the right to modify or terminate this program at any time. My signature certifies that the medication received from BMSPAF will not be resold nor offered for sale, trade or barter and will not be returned for credit. I understand that BMSPAF reserves the right to recall or discontinue product at any time without notice. Healthcare Provider Signature: Date:

Source: https://bugg.benefitscheckup.org/cf/forms/AbilifyPatientAssistanceProgram.pdf