Schedule B
Salud a Su Alcance
Pharmacy Assistance Program
ENROLLMENT FORM
Prescription Plan or Prescription Card (if any): ________________
Are you enrolled in the Epic Program: _______________
Name: ___________________ #9; ________________________
(Please Print Clearly)Address: #9; ________________________________________________
City, State, Zip
________________________________________________Telephone Number: ____ -_____ - _________________
Date of Birth: ______ _______________
Social Security Number: ____ - ____ - _________________
Marital Status (circle one): single married divorced separated widowed
Sex (circle one): 9; male female Household Size: _______________________________
Primary Insurance: _____________
Source of Income: ð Wage/ ð Support by Family/ ð Alimony/ ð Pension/ Social Security/ ð None/ ð Other: _____________________
Monthly Household Income: $______________________________
Diagnosis: (1) ____________, (2)_______________, (3) ______________ (4) __________
Year Diagnosed: ____________ ______________ ______________ __________
Name of Physician: _____________________________
Please initial over the appropriate box: (These are not conditions for participation)
ð__ I permit my Provider to discuss any improvement of my health status as a result of my participation in this program
ð __I agree to participate in surveys regarding my experience with the Pharmacy Assistance Program conducted by SASA Community Access Program.
**All information will be used solely for the purpose of improving the quality of the Pharmacy Assistance Program**
Date
I, ________________________ consent to be enrolled in the Pharmacy Assistance
Program. I fully understand the nature of the Pharmacy Assistance Program and will adhere to the Patients’ Enrollment Guidelines that I was given. By signing this consent I authorize SASA-PAP staff to share with the pharmaceutical manufacturers the information I provided on this form for the sole purpose of obtaining my medication through their Patient Assistance Program.I also understand that SASA-PAP requires proof of income or a statement of benefits to provide verification for eligibility and by signing this consent I give permission to SASA-PAP to obtain this proof of income or statement of benefits from my health care provider or community health facility.
Furthermore I authorize the coordinator for the SASA-PAP program to sign and date all documentation/forms that are sent to any of the participating pharmaceutical companies on my behalf. The role of SASA-PAP shall be limited to administrative functions and signatory power in reference to eligibility forms that are submitted to the participating pharmaceutical companies for prescription medication.
I understand that by signing this consent form does not automatically qualify me to receive prescription medications from the participating pharmaceutical companies, which have their own guidelines.
______________________________________ _________________
(Patient Signature) Date